safety practice questions

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? 1. Wear dark-tinted eyeglasses 2. Keep a light on in the room at all times. 3. Close the window blinds during the day. 4. Call for assistance when getting out of bed.

4

A nurse is caring for a client who fell by the side of the bed when attempting to use the commode. What should the nurse do FIRST when completing responsibilities associated with this situation? 1. Initiate the incident report. 2. Notify the nursing supervisor of the event 3. Document the incident in the client medical record. 4. Have a primary health provider examine the client immediately

4

Which intervention is effective in reducing the major cause of injury in the hospital setting for clients who are older adults? 1. Assist all older adults with toileting activities. 2. Elevate the bedside rails of older adults at night. 3. Place a fall precaution sign on the door to a room with an older adult. 4. Identify medications taken by older adults that may increase the risk of falls.

4

Which are important steps when transferring a client from a bed to a chair using a mechanical lift? Select all that apply. 1. Position the chair as close as possible to the bed. 2. Remove the sling after the transfer is completed. 3. Position the sling from the middle of the clients back to the ankles. 4. Spread the legs of the lift apart before lowering the client to the chair. 5. Attach the longer straps to the lower grommets on each side of the sling.

4 and 5

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 order of least restrictive to most restrictive that may be employed to ensure the safety of the 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

A nurse is caring for a client who have a vaginal radiation implant. What essential actions should the nurse implement when caring for the client? select all that apply. 1. Maintain the client in the semi-Fowler position. 2. Have the client wear a detection badge while receiving care. 3. Talk with the client while standing at the foot of the client's bed. 4. Wear a let apron when providing direct nursing care to the client. 5. Instruct visitors that they can stay a half hour daily and to sit at the door. 6. Keep soiled linens in the rom until surveyed by a radiation safety staff member.

4, 5, 6

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? 1. Get another staff member and go to the room together. 2. Have a security guard handle the situation. 3. Ask what is going on and then set limits. 4. Go to the room and try to intervene.

1

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? 1. Assessing balance 2. using a bed alarm 3. encouraging the use of a walker 4. teaching to rise slowly from a sitting to standing position

1

An 87 year old adult is admitted to the hospital for diagnostic tests and intravenous rehydration therapy after a fall in the home. The next day the clients prescription for "out of bed to chair" twice daily was changed to " out of bed ad lib." What should the nurse do before getting the client out of bed? 1. Test the strength of client's legs. 2. Take BP while the client is supine. 3. Give the client oxygen via a nasal cannula for several minutes. 4. Disconnect the client's intravenous tubing from the venous access device.

1

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. 1. Encourage the client to wear prescribed hearing aids. 2. Provide a telephone, radio, and talking books. 3. Encourage the purchase of a talking watch. 4. Provide a foot bath and a back massage, 5. Speak in a high tone of voice.

1, 2, 3, 4

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. 1. Check the site of the restraint every 30 minutes. 2. Remove the wrist restraints to provide skin care every 2 hours. 3. Ensure that the wrists are well padded when applying wrist restraints. 4. Permit 3-finger widths to slide between the clients skin and the restraints. 5. Tie the straps of the wrist restraints to the frame of the bed using a slop knot.

1, 2, 3, and 5

Which nursing actions should the nurse implement when ambulating a client with a gait belt? select all that apply. 1. Position yourself slightly behind a next to the client when ambulating a client with a gait belt. 2. Adjust the belt so that no fingers can be inserted between the belt and the clients waist. 3. Stand on the clients weaker side when ambulating with a gait belt. 4. Assess for activity intolerance while ambulating a client with a gait belt. 5. Hold the gait belt in the middle of the clients back.

1, 3, 4, 5

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. 1. Practice a home fire escape plan. 2. Smoke cigarettes in just one room of the home. 3. Install smoke alarms near bedrooms and stairs. 4. Install a class A extinguisher close to the kitchen. 5. Teach participants how to stop, drop, and roll if clothing is on fire.

1, 3, 5

Warm compresses are prescribed to be applied to the insertion site of an intravenous catheter that had become red and inflamed. What should the nurse explain to the client that is the desired outcome of the therapy? 1. "The area will feel less tense, which will decrease the risk of bleeding." 2. "Circulation to the area will increase, which will promote healing." 3. Circulation to the area will decrease, which will limit edema." 4. "The area will feel numb, which will decrease comfort."

2

A nurse is caring for a client who is blind. What should the nurse do the facilitate client safety? Select all that apply 1. Encourage the client to have a bed bath rather than a shower. 2. Walk about a foot ahead and have the client grasp your arm. 3. Provide a small light in the room and the bathroom at night. 4. Remain nearby when the client is providing self care. 5. orient the client to the physical environment. 6. Provide cold rather than hot drinks.

2, 4, 5

Which nursing interventions can give a client a sense of control regarding personal safety? select all that apply. 1. inform the client why an ID band should be worn. 2. Instruct the client on how to lock the wheels on a wheelchair. 3. Keep the clients bed in the lowest position. 4. Teach the client how to use the call bell. 5. Orient the client to the environment.

2, 4, 5

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? 1. Raise all of the bedside rails. 2. Ensure that the water pitcher has fresh water. 3. Lower the height of the bed to the lowest position. 4. Position the bed pan in easy reach under the covers.

3

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. 1. Obtain a sedative to be administered to the client at bedtime. 2. Apply a vest restraint when the client plans to go to sleep. 3. Apply a radio frequency product to the client's wrist. 4. Restrict fluids several hours before bedtime. 5. Activate the bed alarms on the bed. 6. Eliminate caffeine products from the diet.

3, 4, 5, 6

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. 1. Check the restraint every 2 hours. 2. Release the restraint every 4 hours. 3. Tie the restraint to the movable part of the bed frame. 4. Provide skin care every 3 hours when a client has a restraint. 5. Ensure that the cross-over of the vest restraint is in front if the client

3, 5