Safety Practice questions
Which of the following patients is at greatest risk for experiencing a fall? A) A confused patient with a history of a previous fall. B) A patient who ambulates by holding onto furniture. C) A recently admitted patient. D) A patient who wears glasses to read.
A
The nurse manager is reviewing the use of restraints during an in service with the staff. Which of the following should NOT be included in the discussion? A) Physical restraints provide a safe and reliable method to prevent falls without serious complications. B) When all side rails are raised, this may be considered a form of physical restraint. C) Two fingers should be able to fit underneath the restraint. D) Attach the restraint to the movable part of the bed frame.
A
What is the purpose of a gait belt? A) It provides a means to steady a patient at the center of gravity or to transfer a patient safely without pulling on the patient's body. B) It keeps a patient from ambulating too fast. C) It measures the distance a patient has ambulated. D) It identifies patients who are at risk for a fall and who require a physical therapist to ambulate. E) It is a type of restraint
A
What should the nurse do prior to administering physical restraints? A) Initially, provide a restraint-free environment. B) Warn the patient that restraints will be used if he or she does not cooperate. C) Move the patient to a room without a roommate and away from the nurses' station. D) Wait until the patient has actually fallen.
A
A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? A) Notify the health care provider for follow-up evaluation. B) Tie the restraints to the bedside rail or frame of the wheelchair. C) Tie the restraint straps in a knot so the patient does not get loose. D) Assess, but avoid removing the restraints every 2 hours since the patient is violent.
A
The NAP is reviewing with the nurse how to apply a belt restraint. Which statement, if made by the NAP, indicates further teaching is necessary? A) "I should place the belt restraint around the chest or abdomen." B) "A properly applied belt restraint allows the patient to turn onto his side." C) "I should apply the belt over the patient's gown or pajamas." D) "To apply the belt restraint, I should first have the patient sit up in bed."
A
The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? A) On the patient's left side. B) On the patient's weak side. C) It doesn't matter, since you are assisting the patient. D) Whichever side the patient prefers.
A
The nurse walking down the hospital corridor glances into the patient's room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room and determines that the patient has fallen. What actions should be taken? (Select all that apply.) A) Call for assistance. B) Assess for injury. C) Notify the health care provider. D) Avoid moving the patient until the health care provider arrives. E) Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). F) Apply a restraint after returning the patient to bed. G) Fill out an incident report.
A, B, C, E, G
A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: Select all A) Prolonged bed rest. B) Hypokalemia. C) Low body weight. D) Antihypertensives. E) Room temperature.
A, B, D
Which of the following are appropriate measures to help the patient with dysphagia to swallow and prevent aspiration? Select all A) Add thickener to thin liquids. B) Place food on the unaffected side of the mouth. C) Provide the patient with a lap protector. D) Place the patient in the high-Fowler's position. E) Provide verbal coaching. F) Talk about other matters while feeding the patient.
A, B, D, E
The daughter of an elderly patient comes to visit her mother who was recently admitted to the hospital. The daughter notices a yellow band on her mother's wrist and asks what it is for. The nurse correctly responds that it is used to identify patients who are at risk for falling and provides additional information as to what makes a patient a fall risk. What information should the nurse include? Select all A) Age over 65. B) New and different environment. C) Continent of urine and bowel. D) History of a fall. E) Having an IV. F) Taking muscle relaxants.
A, B, D, E, F
The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis? Select all A) Skin integrity and ROM. B) Pulse and temperature of restrained body part. C) Ability of patient to breathe without restriction. D) Readiness for discontinuation of restraint. E) Presence of visitors. F) Therapy (e.g., IV catheters, drainage tubes) remains uninterrupted.
A, B, D, F
The nurse checks the patient's extremity restraints hourly. What is the nurse looking for related to this type of restraint? Select all A) Distal pulses. B) Temperature of the skin distal to the restraint. C) Whether the patient wants the restraints released. D) Proper placement of the restraint. E) The character of respirations. F) Sensation of the distal part of the extremity. G) The patient's blood pressure. H) Color of skin distal to the restraint.
A, B, D, F, H
The nurse is providing an in-service on patient safety and reducing the risk of patient falls. What information should the nurse include in this discussion? Select all A) Organize a predictable daily routine that alternates activity and rest for the patient. B) Respond promptly to a patient's call light. C) Discourage family from staying with the patient at night. D) Push the wheelchair in a forward direction out of the elevator. E) Keep the bed in a low locked position.
A, B, E
A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? Select all A) Explain the use of the call light. B) Keep the bed in the low, locked position. C) Keep all side rails up when patient is in bed. D) Place a bedside commode near bed. E) Ensure that the pathway to the bathroom is clear. F) Keep patient's personal items (e.g., book, reading glasses, watch, comb) on the over-bed table.
A, B, E, F
Which of the following patients would require repositioning? (Select all that apply.) A) A patient in correct body alignment who was turned 2 hours ago. B) A patient who has been sitting in a chair for 10 minutes watching television. C) A patient with paraplegia who has been sitting in a chair for 30 minutes but states she is comfortable. D) A patient who was repositioned for comfort 30 minutes ago after being moved up in bed.
A, C
A patient has been recently admitted to the hospital. What indications, if observed, may suggest that the patient has dysphagia (difficulty swallowing)? Select all A) Persistent drooling. B) Drowsiness. C) Change in voice after swallowing. D) Wet, gurgly voice. E) Loss of appetite
A, C, D
If a patient has dysphagia (difficulty swallowing), which of the following foods found on the patient's tray may be cause for concern or require further intervention? Select all A) Grape juice. B) Oatmeal. C) Sausage patty. D) Toast with butter. E) Scrambled eggs.
A, C, D
Who may require a temporary restraint? (Select all that apply.) A) A patient who is at risk for falls when nonrestrictive measures have failed. B) A patient who is uncooperative. C) A confused patient who may interrupt prescribed therapy, such as a nasogastric tube. D) A patient who may be at risk to self or others. E) A patient who walks in his or her sleep.
A, C, D
The nurse is caring for an elderly person who has suffered a stroke and now has left side weakness and dysphagia. The nurse is being very careful to prevent the patient from aspirating by taking which of the following measures? Select all A) Having the patient maintain an upright position for 30 to 60 minutes after eating. B) Placing the food on the patient's left side of the mouth. C) Placing the food in the middle of the tongue toward the back of the mouth. D) Having the patient tilt her head forward slightly when swallowing. E) Placing 1 tablespoon of food in the patient's mouth and following it with liquid.
A, D
Which of the following can be delegated? Select all A) Transfer from bed to chair. B) Determining a dependent patient's risk for aspiration. C) Completing a fall risk assessment tool. D) Applying restraints. E) Moving a patient with an acute spinal cord injury up in bed.
A, D
A patient has severe rheumatoid arthritis affecting her hands. What measures can be taken to facilitate optimum nutrition? Select all A) Determine the patient's food preferences. B) Provide the patient with finger foods such as raisins, nuts, grapes, and cheese cubes. C) Identify the food location on the plate as if it were a clock. D) Provide adaptive utensils (e.g., large handles). E) Attach a plate guard to the plate.
A, D, E
Which of the following are appropriate safety measures for the use of a wheelchair? Select all A) Brakes on both wheels are locked when the patient is being transferred into the wheelchair. B) Brakes on the side nearest the bed are locked when the patient is being transferred into the wheelchair. C) Keep footplates lowered for transfer into the wheelchair. D) Back the wheelchair into and out of an elevator. E) Stand behind the wheelchair when going down a ramp or incline. F) Seat the patient in the wheelchair with buttocks against the back of the seat.
A, D, F
A)Mitten restraint B)Belt restraint C)Elbow restraint D)Extremity restraint Definitions: 1)Immobilizes one or all extremities 2)Prevents the use of fingers to scratch skin, remove dressings, or dislodge equipment 3)Prevents a patient from reaching head and face to dislodge tubes or dressings 4)Maintains a patient in a bed or stretcher
A-2, B-4, C-3, D-1
A hospitalized elderly patient is disoriented to time and place, and the NAP reports the patient has been pulling at the indwelling catheter. The nurse just replaced the Foley catheter an hour ago after the patient pulled it out. After a focused assessment of the patient, the nurse determines the use of restraints is appropriate. What action should the nurse take next? A) Apply the restraints immediately. B) Have the NAP stay with the patient and call the health care provider. C) Call the patient's family and obtain consent. D) Have the NAP apply restraints and assess application 1 hour later.
B
A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed should the nurse place the wheelchair? A) On the patient's weak (affected) side. B) On the patient's strong (unaffected) side. C) Either side of the bed. D) Whichever side the patient prefers.
B
Two nurses are assisting a patient to move up in bed with a lift sheet, and the patient is unable to assist. Which of the following actions is inappropriate? A) Remove pillow, lower the head of the bed to the lowest position the patient can tolerate, and lower the side rails. Have bed at working height. B) Place the pillow at the head of the bed. Roll the patient side to side and place a lift sheet under the patient that extends from the waist to the knees. C) With one nurse on each side of the patient, grasp the lift sheet firmly with hands near the patient's upper arms and hips, fanfolding the sheet close to the patient. Flex knees with body facing the direction of the move. D) Instruct the patient to rest the arms on the body and to lift the head on the count of three. Lift the patient toward the head of the bed on the count of three. Repeat the move if necessary.
B
Why are most health care facilities no longer using vest (jacket) restraints? A) Because they are difficult to apply and remove. B) Because they have been associated with fatal injuries. C) Because they are less cost effective than other restraints. D) Because patients are able to get out of them more easily
B
An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? Select all A)Use a security camera to monitor when the patient tries to get out of bed. B) Use a battery-operated alarm attached to the patient's leg. C)Use a weight-sensitive alarm placed under the patient in a chair or in bed. D)Use a tether alarm attached to a chair, bed, or doorway and clipped to the patient's garment. E)Increase infusion of IV fluids to reverse fluid imbalance.
B, C, D
What are some examples of "verbal coaching" that can be used when feeding the adult dependent patient who has difficulty swallowing? Select all A) "Green beans are very nutritious." B) "Open your mouth." C) "Let's turn on the television and see what's cooking on the Food Network." D) "Raise your tongue to the roof of your mouth." E) "Close your mouth and swallow."
B, D, E
Which of the following patients should be allowed to lie back down? A) A patient who was just transferred to a chair and states she was more comfortable in bed. Health care provider's orders are to be up in chair twice daily. B) A patient whose blood pressure was 120/80 prior to transfer, and is now 112/78. C) A patient who complains of feeling dizzy and slightly nauseous when dangling on the bedside. D) A patient whose blood pressure was 110/70 prior to transfer, and is now 125/80.
C
Which of the following would be a correct action of the NAP in regard to the application of restraints? A) The NAP removes the restraints every 24 hours for an hour. B) The NAP may apply restraints to patients if the NAP determines that it is necessary, as long as the NAP informs the nurse after doing so. C) The NAP removes one restraint at a time in a patient who is violent. D) The NAP may keep the patient's bed at a working height while the patient is in restraints.
C
In the change of shift report, the nurse was told a patient requires "minimal assistance with meals." What should the nurse expect to do for the patient at mealtime? Select all A) Place the meal tray in the room, leave the room, and return in 30 minutes to remove the tray. B) Feed the patient. C) Open packages and cartons. D) Assist the patient to an upright position. E) Ask the patient if he or she needs the nurse to cut up the food or butter the bread. F) Document the intake
C, D, E, F
A hospitalized patient has repeatedly refused her meals. What should the nurse do? Select all A) Offer to feed patient. B) Administer vitamins with minerals to the patient. C) Determine the patient's food preferences. D) Apply more seasonings to foods. E) Determine whether the patient is in pain or has anxiety requiring treatment.
C, E
The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction? A) The NAP inserted two fingers under the secured restraint. B) The NAP used a quick-release tie. C) The NAP placed the patient in functional alignment. D) The NAP attached the restraint to the side rail of the bed.
D
The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? A) Notify the health care provider immediately. B) Give the patient some water. C) Allow the patient to rest. D) Suction the airway as necessary.
D