Safety

A community-health nurse is providing a program about fire safety in the home. What recommendations should the nurse include in this program? Select all that apply. A) Practice a home fire escape plan. B) Smoke cigarettes in just 1 room of the home. C) Install smoke alarms near bedrooms and stairs. D) Install a Class A extinguisher close to the kitchen. E) Teach participants to stop, drop, and roll if clothing is on fire.

Correct answer: A,C,E Not D because class A extinguisher isn't the proper extinguisher for the kitchen

Which intervention is effective in reducing the major cause of injury in the hospital setting for clients who are older adults? A) Assist all older adults with toileting activities. B) Elevate all bedside rails of older adults at night. C) Place a fall precaution sign on the door to a room with an older adult. D) Identify medications taken by an older adult that may increase the risk of falls.

Correct: D. Assessment is the first step in the nursing process. Assessments should be completed before planning and implementing care. Older adults often experience one or more chronic illness and receive a variety of medications. Polypharmacy is a risk factor for adverse reactions and drug interactions that may cause an older adult to fall. A. Assisting all older adults with toileting activities is not client centered. Not all older adults need to be assisted with toileting activities. This promotes dependence and violates the client's right to privacy if assistance is unnecessary. B. Elevating all bedside rails of older adults at night is not client centered. Not all older adults need all side rails raised at night. Side rails are considered a restraint when all of them are raised. Unless it is requested by the client, the use of all side rails requires a prescription from a primary health-care provider for a specific reason that is documented. C. Placing a fall precaution sign on the door to a room with an older adult is not client centered. Not all older adults require fall precautions beyond the average interventions implemented to maintain physical safety for all adult clients. In addition, a sign indicating fall precaution violates the client's right to privacy. Facilities generally use a sign such as a flower to indicate to staff that a client is at risk for falls.

A nurse is caring for a client who is hearing impaired and legally blind. What should the nurse do to prevent a sensory deficit? Select all that apply. A Encourage the client to wear prescribed hearing aids. B Provide a telephone, radio, and talking books. C Encourage purchase of a talking watch. D Provide a foot bath and back massage. E Speak in a high tone of voice.

Correct: A, B, C, D A. Hearing aids will enhance hearing, which should help prevent the sense of isolation. B. A telephone, radio, and talking books will help to stimulate the client (e.g., hearing, thinking, socialization). C. When a button is pushed, a talking watch reports the time. This will help to keep the client oriented to time, which is stimulating. D. A foot bath and back massage will provide for tactile interaction with the caregiver, increasing stimulation. E. People with impaired hearing tend to have a reduced ability to hear high-pitched tones. The nurse should use a lower tone when speaking with a client who is hearing impaired.

A nurse is caring for an older adult who is cognitively impaired and has a history of pulling out tubes and falling. List the following safety devices in the order of least restrictive to most restrictive that may be employed to ensure the safety of this client. 1. Cloth vest 2. Two wrist straps 3. Four side rails up 4. Bed exiting alarm device 5. Four-point restraint tied to the bed frame

4, 3, 1, 2, 5 4. A bed-exiting alarm device will signal caregivers when the client attempts to exit the bed. These devices do not restrict the client's movement but will alert staff members that the client needs supervision. This is a safety device that does not require a prescription from a primary health-care provider. 3. Although four side rails will confine the client to the bed, the client is still able to turn and sit up with ease. 1. A cloth vest permits turning from side to side and sit- ting up but physically restricts the client to the bed by the use of straps tied to the bed frame. 2. Two wrist restraints restrict the movement of the upper extremities and prevent turning from side to side; also, they confine the client to the bed because the straps are tied to the bed frame. 5. A four-point restraint is the most restrictive physical restraint because the extremities are for all practical purposes immobilized; all four extremities are tied to the bed frame.

A nurse has a prescription to apply wrist restraints to maintain a client's safety. What should the nurse do when applying this type of restraint? Select all that apply. A) Check the site of the restraint every 30 minutes. B) Remove the wrist restraints to provide skin care every 2 hours. C) Ensure that the wrists are well padded when applying wrist restraints. D) Permit 3 finger-widths to slide between the client's skin and the restraints. E) Tie the straps of the wrist restraints to the frame of the bed using a slip knot.

Correct: A, B, C, E A. The site of the restraint should be checked every 30 minutes to ensure that circulation and/or breathing are not affected depending on the type of restraint as well as the client's response to the restraint. B. Removing the wrist restraint should occur at least every 2 hours and more frequently if determined to be necessary. In addition, when restraints are released, skin care should be provided to promote tissue integrity. C. Well-padded wrist restraints help to prevent injury to the wrists. E. A slip knot should be used to permit a quick release of the straps in the event of an emergency. Tying the straps of the wrist restraints to the immovable frame of the bed protects the client from injury when the bed position is altered or the side rails are raised or lowered. D. Three finger-widths between the client's wrist and the restraint will make the restraint too loose. Two finger-widths are sufficient to ensure that the client's circulation is not impaired and yet tight enough for the restraints to remain secured around the client's wrists.

Which nursing actions should the nurse implement when ambulating a client with a gait belt? Select all that apply. A Position yourself slightly behind and next to the client when ambulating a client with a gait belt. B Adjust the gait belt so that no fingers can be inserted between the belt and the client's waist. C Stand on the client's weaker side when ambulating a client with a gait belt. D Assess for activity intolerance while ambulating a client with a gait belt. E Hold the gait belt in the middle of the client's back

Correct: A, C, D, E A. The caregiver should walk slightly behind and next to the client being ambulated with a gait belt. This enables the caregiver to hold the belt handle in the center of the back as well as grab the handle on the side if the client needs more assistance with balance. C. Walking on the client's weaker side provides better support of the client when the client shifts weight to the weaker side when ambulating. D. Clients who need a gait belt when being ambulated generally have impaired balance or are weak and, therefore, must be assessed for clinical indicators of activity intolerance. It is not acceptable to just make this assessment after the completion of ambulation. E. Holding a gait belt at the location of the client's back allows the caregiver to quickly control the client's balance.

A nurse is caring for a 60-year-old adult who is a resident in a rehabilitation center recovering from a right-sided brain attack (cerebrovascular accident, stroke). The client has a prescription for out-of-bed ambulating with assistance as tolerated. Which intervention is most important? A) Assessing balance B) Using a bed alarm C) Encouraging the use of a walker D) Teaching to rise slowly from a sitting to standing position

Correct: A. Assessment is the first step of the nursing process. The nurse must first assess the client for the presence of problems with strength and balance before moving a client out of bed. People with problems with balance may not be able to maintain the sitting position while sitting on the side of the bed. B. A bed alarm is unnecessary. There is no information in the stem that indicates that the client is confused or un- willing to call for assistance when getting out of bed. C. Encouraging the use of a walker is implementing an intervention before the client's needs are assessed. D. Although teaching a client to rise slowly from a sitting to standing position should be done, it is not as critical as another option.

A nurse is caring for a client with wrist restraints. Which actions should the nurse implement when caring for this client? Select all that apply. A Release the restraints every 3 hours and provide skin care. B Provide additional padding when applying a wrist restraint. C Offer fluids and assist the client to toilet every time the restraints are released. D Check on the client every hour and ensure that circulation is not impaired by the restraints. E Ensure that every 24 hours the primary healthcare provider assesses the need for the restraints.

Correct: B, C, E B. Additional padding when applying a wrist restraint protects bony prominences from pressure and tissue abrasion. C. When a restraint is removed, the nurse should assess for the presence of edema, capillary refill, sensation, function, skin integrity, and erythema. In addition, the client should be offered fluids and the opportunity to go to the bathroom. Finally, skin care and range-of-motion exercises should be provided and the client's position changed before restraints are reapplied. E. A primary health-care provider must renew the prescription for restraints every 24 hours. In addition, a progress note should indicate why the restraint is still needed. A. Restraints must be released every 2 hours, not 3 hours. D. Circulation should be checked every 30 minutes, not every hour.

Which nursing interventions can give a client a sense of control regarding personal safety? Select all that apply. A) Inform the client why an identification band should be worn. B) Instruct the client how to lock the wheels on a wheelchair. C) Keep the client's bed in the lowest position. D) Teach the client how to use the call bell. E) Orient the client to the environment.

Correct: B, D, E B. Instructing the client how to lock the wheels on a wheelchair allows the client to provide safe self-care when in a wheelchair. D. The ability to call for help when needed gives the client a sense of control. E. Having an understanding of the environment (e.g., how to use a call bell, how to raise and lower the bed, and how to use the side rails when turning or transferring) gives the client a sense of control. A. Although wearing an identification band will provide for client safety, it does not give the client a sense of control. C. Keeping the client's bed in the lowest position will not give the client a sense of control.

A nurse is caring for a client who is blind. What should the nurse do to facilitate client safety? Select all that apply. A Encourage the client to have a bed bath rather than a shower. B Walk about a foot ahead and have the client grasp the nurse's arm. C Provide a small light in the room and bathroom at night. D Remain nearby when the client is providing self-care. E Orient the client to the physical environment. F Provide cold rather than hot drinks.

Correct: B, D, E B. Walking about a foot ahead and having the client grasp your arm is the proper way to assist a client who is blind with ambulation. By walking slightly ahead and with the client holding the nurse's arm, the nurse is able to guide the client around obstacles. D. Remaining nearby enables the caregiver to intervene if the client's safety is jeopardized. E. Orienting the client to where furniture and equipment are located in the room provides a frame of reference for the client. A. With guidance or supervision, a client who is blind can shower safely. C. The client is blind. A nightlight will not help this client to see.

A nurse is transferring a weak, older adult from a bed to a toilet using a sit-to-stand lift. What is the most important reason why a nurse uses this device rather than a gait belt to transfer a client to a toilet? A Encourage independence B Protect the nurse from injury C Promote muscle development D Support psychological well-being

Correct: B. Both the nurse and client are protected from injury when the nurse uses this device to transfer the client from a chair/bed to a commode/toilet. It is designed for individuals who can bear some weight in an upright position, but who are weak or recovering from surgery. A. Although the client participates to some degree in a transfer with a sit-to-stand lift by partially bearing weight and holding onto the handles of the device, encouraging independence is not its primary purpose. C. Although weight bearing in the upright position and holding onto the handles of the sit-to-stand device may require muscle contraction promoting muscle strengthening, it is not its primary purpose. D. Although the client participates to some degree in a transfer with a sit-to-stand lift by partially bearing weight and holding onto the handles of the device, encouraging independence and psychological well-being, it is not its primary purpose.

A nurse is ambulating a client in the hall several rooms away from the client's room. During the walk, the client states, "I feel so dizzy and weak; I don't think that I will make it back to the room." What action should be implemented at this time? A) Return the client to bed quickly. B) Lower the client to the floor gently. C) Walk toward the client's room slowly. D) Call another nurse to assist the with client immediately.

Correct: B. Lowering the client to the floor gently allows the nurse to prevent the client's head from hitting the floor. It controls the client's movement toward the floor, preventing injury to both the client and nurse. A. Returning the client to bed quickly is inappropriate and unsafe. Rapid movements will exacerbate the client's feeling dizzy, and the client is feeling weak and will not be able to move quickly. C. Slowly walking back to the client's room when the client feels weak and dizzy may result in the client falling, injuring both the client and nurse. D. Calling for another nurse to assist is an admirable intervention, but there may not be enough time for the nurse to arrive to be of assistance.

A client is confused and trying to pull out an indwelling urinary catheter. The nurse tried various interventions to protect the client from pulling out the catheter to no avail. The nurse notifies the primary health-care provider and asks for a prescription for a restraint. What type of restraint should the nurse anticipate will be prescribed? A Belt B Mitt C Vest D Wrist

Correct: B. Mitt restraints are the least restrictive of the restraints presented in the options and are most appropriate for this client. A mitt restraint permits the client to move the upper extremities but will not permit the client to grasp a catheter. A. A belt restraint is applied around a client's abdomen and tied to the base of a bed or behind a chair to prevent a client from getting out of a bed or chair without assistance. The upper and lower extremities have free range of motion. It does not protect a client from pulling out a catheter. C. A vest restraint does not protect a client from pulling out a catheter. It protects the client from leaving a bed or chair without assistance. The upper arms and hands have free range of motion. D. A wrist restraint is more restrictive than a restraint presented in another option. Although a wrist restraint may prevent pulling out a catheter, it unnecessarily prevents free range of motion of the upper extremities.

A nurse is completing a client assessment for the purpose of determining factors that place the client at risk for falls. Which factor should cause the most concern when completing this assessment? A Uses a walker B Has a history of falls C Takes a diuretic twice a day D Has a urinary retention catheter

Correct: B. Most assessment tools indicate that a history of a recent fall is a significant factor regarding the risk for a future fall. A. Although a client using a walker is a concern in relation to safety, it is a less significant predictor of the potential for a fall than another option. C. Although a client receiving a diuretic is at risk for hypotension, which is a concern, it is a less significant predictor of the potential for a fall than another option. D. Although a urinary retention catheter is a concern in relation to safety, it is a less significant predictor of the potential for a fall than another option.

A client who is cognitively impaired is admitted to the hospital for pneumonia. The client has a history of wandering at night. What should the nurse do to meet the needs of this client? Select all that apply. A) Obtain a sedative to be administered to the client at bedtime. B) Apply a vest restraint when the client plans to go to sleep. C) Apply a radio frequency product to the client's wrist. D) Restrict fluids several hours before bedtime. E) Activate the bed alarm on the client's bed. F) Eliminate caffeine products from the diet.

Correct: C, D, E, F C. A radio frequency product worn on the wrist or ankle or as a pendant alerts the caregiver when a client approaches an area of egress that is unsafe for the client. D. Restricting fluids several hours before bedtime may reduce the need to void during the night. A cognitively impaired person may feel the need to void during the night and exit the bed to find a bathroom. E. A bed-exiting device (e.g., position sensor on the leg, weight sensor under the mattress of a bed) should be used to alert caregivers when the client is attempting to exit the bed. A health team member should immediately assist the client and maintain safety when the alarm sounds. F. Caffeine is a stimulant. Removing caffeine products from the diet may help reduce wandering at night. A. A chemical restraint should be used as a last resort. Clients have a right to have the least restrictive restraint used to promote safety. B. A vest restraint is too restrictive a device to use before a less restrictive method is proven unsuccessful.

A nurse is caring for a client who has a prescription for a vest restraint. Which actions should the nurse implement? Select all that apply. A) Check the restraint every 2 hours. B) Release the restraint every 4 hours. C) Tie the restraint to the movable part of the bed frame. D) Provide skin care every 3 hours when a client has a restraint. E) Ensure that the cross-over of the vest restraint is in the front of the client.

Correct: C, E C. A vest restraint should be tied to the movable part of the bed frame. If the restraint is tied to the immovable part of the bedframe, the client may be injured or the restraint may become too tight and impair respirations when the head of the bed is raised. If the head of the bed is lowered, the restraint will become too loose. E. The cross-over of a vest restraint should be in the front of the client, not the back. If the vest was applied with the cross-over in the back and the client should slide down in the bed, the collar edge could choke the client. A. A client with a restraint should be checked every 30 minutes, not every 2 hours, to ensure client safety. The restraint should not be too tight or too loose. The nurse should check the client's circulation and ensure that there is room to insert two finger-widths between the restraint and the client. B. Restraints should be released every 2, not 4, hours so that the client can receive exercise and skin care. D. Skin care should be provided every 2, not 3, hours when a restraint is removed and range-of-motion exercises provided.

A nurse just finished a complete bath for a client with limited mobility. Which action is most important for the nurse to perform before leaving the bedside of the client? A Raise all of the bedside rails. B Ensure that the water pitcher has fresh water. C Lower the height of the bed to the lowest position. D Position the bedpan in easy reach under the covers.

Correct: C. All clients should have their beds maintained in the lowest position unless a member of the health-care team is providing direct care. This supports client safety. It enables mobile clients to more easily enter and exit the bed. Also, if a client should fall out of bed accidentally, the bed is closer to the floor, which may minimize client injury. A. Raising all the side rails on a bed is considered a restraint. It can be requested by the client or prescribed by the primary health-care provider if necessary. This prescription must be rewritten every 24 hours. A progress note must address the reasons for the restraint and what other measures were tried that were ineffective. B. Although it is important for a client to have fresh water and ice if preferred and permitted, it is not as important as another option. D. A client with limited mobility generally will not be able to use a bedpan unassisted.

A home health-care nurse is visiting a client recently discharged from the hospital to the home. The client has a history of violence. What is important for the nurse to do when caring for this client? A) Apply restraints if the client engages in threatening behavior. B) Administer a prescribed sedative before providing client care. C) Identify when the level of anxiety is elevating. D) Use gentle touch communicating acceptance.

Correct: C. Identifying when the client's level of anxiety is increasing is the most important nursing action. Assessment is the first step of the nursing process. A client with a history of violence may resort to violence when coping with anxiety. As soon as a nurse identifies that the client's level of anxiety is elevating, the nurse should leave and return when the client is less anxious. A. The nurse should not attempt to apply restraints in a client's home. The nurse should immediately leave the client's home and/or call 911 if the nurse feels in imminent danger. B. This is not the first action of the nurse. Although the client has a history of violence, it does not mean that the client will be violent during this home visit. D. The nurse should never touch a person with a history of violence without permission. Touch may be perceived as a threat and may precipitate a violent client reaction.

A hospitalized older adult who has left-sided weakness as the result of a brain attack (stroke, cerebrovascular accident) has the need to urinate several times during the night. What should the nurse do to ensure client safety? A) Encourage the use of a bedpan at night. B) Keep the light on in the room at night. C) Assist the client to the commode at night. D) Encourage the client to use a walker at night.

Correct: C. The nurse should assist clients who are unstable or have impaired mobility. A commode at the bedside limits the energy the client needs to expend at night when the risk for falls escalates. A. Using a bedpan limits mobility, does not let the client assume the best position for voiding, and unnecessarily limits the client's independence. B. Although having a night light on in the room at night helps with orientation, it does not provide as well for the client's safety needs as another option; the client has a problem with mobility, not vision. D. Although a walker may help with client stability, the client should not be performing this activity independently, especially at night when the risk for falls escalates.

Which are important steps when transferring a client from a bed to a chair using a mechanical lift? Select all that apply. A) Position the chair as close as possible to the bed. B) Remove the sling after the transfer is completed. C) Position the sling from the middle of the client's back to the ankles. D) Spread the legs of the lift apart before lowering the client to the chair. E) Attach the longer straps to the lower grommets on each side of the sling.

Correct: D, E D. Spreading the legs of the lift apart widens the base of support increasing stability of the lift. E. Attaching the longer straps to the lower grommets in each side of the sling is correct. When the longer straps are attached to the bottom of the sling and the shorter straps are attached to the top of the sling, the client will be raised to a sitting position when the lift raises the sling and the client up and off the bed. A. It is not necessary to position the chair as close as possi- ble to the client's bed. Mechanical lifts are designed to move a client completely across a room safely. B. The sling remains under the client after the transfer. It would be difficult or even impossible to remove and then reposition the sling if the client were obese or immobile. C. The sling should start at the shoulders and end at the knees. This completely supports the client for the transfer. If it is too high, the client could slide out from the bottom of the sling. If it is too low, the client could slide out from the top of the sling.

A client who is legally blind says to the nurse, "I once was able to see a little bit, but now I can't see anything." What should the nurse encourage the client to do while hospitalized? A Wear dark-tinted eyeglasses. B Keep a light on in the room at all times. C Close the window blinds during the day. D Call for assistance when getting out of bed.

Correct: D. A client who is in a strange environment and who has a visual impairment is at an increased risk for falls. The client should seek assistance with transfers and ambulating until the client feels comfortable engaging in these activities and the nurse determines that the client is safe to perform this activity unassisted. A. Dark-tinted eyeglasses will not benefit a client who "can't see anything." B. Keeping a light on in the room may help a client with partial vision, but it will be insignificant for a client who "can't see anything." C. Closing window blinds will be beneficial for a client with partial vision who is affected by glare; this intervention will not benefit a client who "can't see anything."

A nurse is caring for a client who fell by the side of the bed when attempting to use a commode. What should the nurse do first when completing responsibilities associated with this situation? A) Initiate an incident report. B) Notify the nursing supervisor of the event. C) Document the incident in the client's clinical record. D) Have a primary healthcare provider examine the client immediately.

Correct: D. Having a primary health-care provider examine the client immediately is the first action that the nurse should implement. The client needs to be examined by a primary health-care provider to ensure that the client has not sustained an injury. A. Initiating an incident report is not the priority intervention when a client falls. However, this should be done eventually. B. Although a nursing supervisor should be notified, it is not the first nursing responsibility associated with a client falling. C. Documenting the incident in the client's clinical record is not the priority intervention when a client falls. However, eventually the incident should be documented in the client's clinical record.

A nurse in the emergency department hears a client and a family member arguing with each other in a room at the end of the unit. What should the nurse do first? A Get another staff member and go to the room together. B Have a security guard handle the situation. C Ask what is going on and then set limits. D Go to the room and try to intervene.

correct: A. The situation needs to be assessed, but a health team member should never enter a volatile situation alone. When entering the room, the health team members should stand between the client/visitor and the door. B. Having a security guard handle the situation is premature and may cause the situation to escalate. C. The nurse is in a vulnerable, unsafe position when going to a volatile situation alone. Setting limits may be unnecessary or may escalate an already volatile situation. Setting limits should not be attempted without adequate staff members readily available. D. The nurse is in a vulnerable, unsafe position when going to a volatile situation alone. Attempting to intervene may result in harm to the nurse.