VNSG 1323: Chapter 19 Prep U Questions

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bath water before stepping in." Explanation: Alterations in sensory perception can have a serious effect on safety. A client whose tactile sense is impaired may not perceive temperature extremes that are a threat to safety. Although all the other statements may be necessary, they do not promote safety.

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?" Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.

The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed?

1 medium banana Explanation: The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will mark off a banana from the menu of a client with latex sensitivity.

A nurse is administering the Hendrich Fall Risk Tool to a client. What is the cutoff Final Risk Score for the client to not be considered at risk for falling? Record your answer using a whole number.

5 Explanation: A score above 5 indicates a high risk of falling.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client. Explanation: The priority is to apply an allergy-alert bracelet to the client so that any member of the interdisciplinary team can quickly identify the latex allergy. All other actions can take place immediately thereafter.

The nurse is caring for a client with a latex allergy. When the dietary tray arrives, the nurse notes that it contains a hamburger with lettuce and tomato, baked potato, apple, chocolate chip cookie, and small serving of milk. What is the appropriate nursing action?

Call Nutrition Services for a plain hamburger. Explanation: The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will need to obtain a hamburger without tomato on it for the client with a latex allergy.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a gasoline fire, what will the nurse identify?

Class B Explanation: Class B fire extinguishers contain carbon dioxide and are used to extinguish fires caused by gasoline, oil, paint, grease, and other flammable liquids. Other answers are incorrect.

A nurse is assessing fire safety in a home in which a single mother and young children live. What information would the nurse include in teaching the mother on how to prevent injury from fires and burns? Select all that apply.

Cook on back burners on the stove, and keep handles turned toward the back. Practice with the children what to do if there is a fire in the home. Set the temperature of the water heater to 120°F (49°C) or less. Teach your children to stop, drop, and roll if clothing catches on fire. Explanation: The nurse should provide instructions for fire and burn safety in the home. Teach the mother to cook on the back burners on the stove and keep handles turned toward the back; children often reach up and pull on handles of pots on the stove. The mother should practice with children what to do if there is a fire in the home. Teach the mother to set the temperature of the water heater to a safe temperature, such as 120°F (49°C) or less. Also, the mother should teach the children to stop, drop, and roll if clothing catches on fire. The home should have a smoke detector in every room, and batteries should be changed twice a year. Teach the mother that changing batteries with the time change in the fall and spring is a good reminder system.

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

Dilute with water or milk Explanation: The decision tree for treating ingested poisons states that if petroleum is ingested, it should be diluted with water or milk, vomiting should be prevented, hydration should be given, and symptoms should be treated. Therefore, it is not appropriate to call 9-1-1, induce vomiting, or administer laxative.

The facility where the nurse works has changed from latex gloves to vinyl, powder-free gloves to protect clients with latex allergies. Which education will the nurse provide to the unlicensed assistive personnel (UAP) about this new type of glove?

Gloves must be changed every 30 minutes to maintain barrier protection Explanation: To maintain barrier protection, vinyl powder and vinyl powder-free gloves should be changed after 30 minutes. Other answers are incorrect.

A nurse is caring for a confused client in a long-term care facility. The client is not allowed to get out of bed. The nurse requests restraints for the client. Which guidelines for the use of restraints should the nurse follow? Select all that apply.

Involve the client's family in the decision and plan of care. Alternatives to restraints and less restrictive interventions must have been implemented and failed. Explanation: The benefit gained from using a restraint must outweigh the known risks for that client. The client has the right to be free from restraints that are not medically necessary. Restraints are not used for the convenience of staff or to punish a client. In a long-term care facility, the client's family must be involved in the plan of care, and must be consulted when the decision is made to use restraints. Alternatives to restraints and less restrictive interventions must have been implemented and failed, and all alternatives used must be documented. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 24 hours.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach. Explanation: The mother should be told to always keep her coffee cup on the counter so that it is out of reach of the toddler. Toddlers are naturally inquisitive and more mobile than infants, and they fail to understand the dangers of looking into a cup, which can have hot contents. Consequently, they are often the victims of accidental poisoning, falls down stairs or from high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. The toddler may not understand fire safety or the consequence even after he has been given instructions. A parent feeding the child is not a usual cause of accidental thermal injury.

Which agent has the potential to affect the integrity of latex gloves?

Oil-based lotions Explanation:Oil-based lotions may adversely affect the integrity of latex gloves.

A nurse is attending to an adolescent client at the health care facility who has sprained an ankle during a soccer match. What is the most common reason for an adolescent to risk injury?

Peer pressure Explanation: The nurse should remember that adolescents risk injury to themselves due to peer pressure. Many adolescents suffer sports-related injuries because they participate in physically challenging activities, sometimes without adequate protective equipment before their musculoskeletal systems can withstand the stress. Adolescents also tend to be impulsive and take risks as a result of peer pressure.

A nurse is assigned to care for a 10 month-old boy. Which activity should be the priority for the nurse?

Protect the toddler from injury Explanation: The highest priority for the nurse should be to protect the toddler form injury because he is at high risk of injury due to his developmental abilities. Sensory stimulation, spending time with the toddler in the play room, and providing health education to parents are not as important as the security of the toddler.

A fire has erupted in the trash can on the unit and the nurse implements the protocol for fire safety for the facility. Another nurse obtains the fire extinguisher and is preparing to use it. What would the nurse do first?

Pull the pin. Explanation: When using a fire extinguisher, the nurse should follow the PASS mnemonic: Pull the pin, aim the nozzle, squeeze the handle and sweep back and forth over the fire.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.

The nursing supervisor is concerned about excessive use of physical restraints on the unit. What interventions would the nursing supervisor employ to decrease the use of restraints? Select all that apply.

Review and change, if needed, current policies at the agency for adherence to accepted national standards. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. Obtain additional bed alarms or position-sensitive electronic devices for use as needed. Explanation:The nursing supervisor who is trying to decrease the use of physical restraints has several interventions that can be employed. Current policies at the agency should be reviewed for adherence to accepted national standards. Policies should be changed, if needed. Classes should be provided for the nursing staff about proper use of restraints, alternatives to restraints, and documentation requirements. The nursing supervisor can evaluate each client in restraints for appropriate use and discuss the use of the restraints with the client's nurses. Alternatives to restraints are using bed alarms and/or position-sensitive electronic devices for clients who may attempt to get out of bed without assistance. Medications that are used to keep the client in bed are considered chemical restraints and not appropriate for use as such.

The nurse is teaching the caregiver of a 1-year old about safety. Which teaching will the nurse include?

Supervise your child on the changing table. Explanation: Infants should be supervised on a changing table. Therefore, it is appropriate to tell the caregiver to supervise the child on the changing table. The other options are not appropriate for infants, but are more appropriate for older children.

Which client would be the most likely candidate for the use of a waist restraint?

A confused elderly client in a hospital who tries to get out of bed following hip surgery Explanation: The least restrictive restraint should be chosen for clients. When using a waist restraint, patients can move their extremities but cannot get out of the chair or bed.

The nurse is making the initial assessment of a client following a surgical procedure with sedation. Place in order the nurse's assessment actions? Use all options.

Airway, breathing, and circulation Level of consciousness and orientation Intravenous access and IV fluids Wounds and tubes Items within the client's reach Explanation:The nurse is performing an assessment following a surgical procedure. The most important assessment is the client's airway, breathing, and circulation. A problem with any of these would indicate a situation requiring immediate action. The nurse would then assess the client's level of consciousness and orientation. Again, an abnormality in these areas could indicate the need for immediate action. Next, the nurse checks the IV site and fluids infusing for patency, solution, and rate. Then, the nurse would assess the client for wounds and the tubes for presence, patency, and fluid color and amount. The paramount concern is for the client. After client assessments are completed, then the nurse checks for the call bell, water if allowed, and other personal items within reach of the client.

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety? (Select all that apply.)

Area rugs kept on the stairs without carpet Dimly lit hallways Waxed floors Explanation: Area rugs kept on the stairs, dimly lit hallways, and waxed floors are hazards that may cause falls. Nonskid mats and decals for the tub are a fall-prevention method. No danger exists from a laundry bag in the corner of the room.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed, despite instructions to remain there. Which initial intervention is appropriate?

Assess for the need to urinate. Explanation: Client needs should be assessed before considering physical or pharmacologic restraint. Confused clients may need to urinate and not urinate in a bed. A nurse should assess to determine why the client is attempting to get out of bed. A chemical restraint is the use of a medication. Raise the side rails is considered a restraint as well as apply a waist restraint.

After performing neuro checks every 2 hours after an ischemic stroke, the nurse determines the client's neurological status is deterioriating. Which nursing action best prevents an adverse outcome in this client's care?

Assessing the client's neurological status more frequently than ordered Explanation: Frequent assessment is integral to the detection of changes in a client's status and in the prevention of adverse outcomes. Assessing a client more frequently than ordered is an appropriate independent nursing action. Documentation is an essential part of nursing care, but does not directly prevent adverse health outcomes. A CT of the client's head may or may not be necessary, and would not be independently ordered by the nurse. Early rehabilitation promotes functional recovery, but does not prevent adverse outcomes during care.

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

Gas stove Explanation: Fire, injury from fire, and fire-related deaths all decreased significantly between 2004 and 2013. Based on data collected by the United States Fire Administration (USFA; 2013), residential fires (31.7%) are second in prevalence only to outdoor fires (39.3%). It is important to note that 80% of all fire deaths occur in the home (Warmack, Wolf, & Frank, 2015). Cooking is the cause of fire in 29.3% of residential cases; some of the other causes include carelessness (9.2%), heating (9%), electrical malfunction (7.9%), appliances (5%), and smoking (2.3%; USFA).

A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse?

Get the victim out of the present environment. Explanation: The nurse should take the client out of the present environment to prevent further inhalation of carbon monoxide. The nurse can go and call for help after the client has been removed from the site because delay in shifting the client can aggravate the condition. Providing oxygen and hyperbaric oxygen can be given once the client is removed from the site, but the first step is to shift the client from the room.

The nurse is caring for a client who scored 3 on the Hendrich II Fall Risk Model. Which intervention is appropriate? (Select all that apply.)

Implement normal fall prevention measures. Document the finding in the electronic health record (EHR). Explanation:A score below 5 on the Hendrich II Fall Risk Model demonstrates that the client is at normal risk (not high risk) for a fall. Normal fall prevention measures should be implemented, and this should be documented.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

In most age groups, motor vehicle accidents are major causes of death. Explanation: Motor vehicles continue to be the major cause of deaths related to unintentional injuries for all age groups up to 80 years. Suicide is not the leading cause of death in adolescents and adults. Safety practices can reduce, but not completely eliminate, workplace risks. Lead exposure is significant but is not a primary cause of death.

The surgical nurse is preparing a client for surgery on the left leg. Which nursing action is appropriate? (Select all that apply.)

Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedure verification protocol. Call for a "time out" immediately before surgery begins. Explanation: To prevent wrong site, wrong procedure, and wrong person surgery, the nurse will mark the left leg as the one intended for surgery, have the client mark the body part intended for surgery, conduct a preprocedure verification protocol, and perform a "time out" immediately before surgery to double-check the all surgical information regarding the client, and required documents. The nurse will never delegate surgical site identification to a UAP.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation, rather than burns. Explanation: Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

A nurse uses a restraint when caring for a client with a psychiatric disorder who has become violent. What would be most important for the nurse to keep in mind?

Nurses may use direct supervision and communication to reorient the client. Explanation: The nurse may use direct supervision and communication to reorient the client. Nurses can use a restraint without the primary health care provider's order in an emergency situation. However, the nurse should obtain such an order as soon as possible. Use of restraint is not a substitute for vigilant nursing care. Knots should be such that they cannot be opened by the client. However, the health care provider should be able to release the knot quickly in an emergency.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

Raising all side rails while the client is in bed Explanation: Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if he climbs out of bed. All the other options would comply with a least restraint policy

The client is confused and wanders at night at home. The daughter who is the caregiver is seeking assistance with this problem. The daughter states, "I am so worried about my father. What can I do and still get some rest at night?" What instructions would the nurse provide to the daughter? Select all that apply.

Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms that her father may wander. Encourage her father to toilet prior to bedtime. Place locks on any doors to the outside that her father would be able to op Explanation: The nurse would tell the daughter, the caregiver, to reduce stimulation, noise, and light in the hours prior to sleep to encourage relaxation and to set an appropriate bedtime routine. For safety reasons, provide sufficient lighting for the client at night should he wander. Another appropriate bedtime routine is toileting prior to bedtime. For safety reasons, locks can be placed on doors so the client is unable to get through and wander outside. Having the client exercise at night is stimulating and would make it more difficult for the client to fall asleep at night.

The home health nurse will visit a client for the first time in the home. What safety measures will the nurse employ when visiting the client? Select all that apply.

Schedule an appointment with the client prior to the visit. Ask the client to secure animals in another room or outside before the visit. Ensure the nurse's automobile is in good condition and can be driven to the client's home. Carry a cell phone at all times. Explanation: Self-care behaviors to promote safety for the nurse include scheduling an appointment for the visit with the client prior to traveling to the home; asking the client to secure animals in another room or outside; keeping the nurse's automobile in good, working order; and carrying a cell phone at all times. The nurse would not carry cash in his or her pocket as this would make the nurse a target for a robbery.

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation. Explanation: Adolescence is a time of rapid physical growth and more sleep is required. Many adolescents try to balance afterschool activities with jobs and school, resulting in sleep deprivation. This, in turn, poses a safety risk as adolescents have increased freedoms, such as driving.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use 3-prong electric plugs whenever possible. Explanation: Nurses work with mechanical and electrical equipment on a daily basis. Proper care to avoid injury and damage to these items includes using them only for the specific purpose, using 3-prong plugs, and having working knowledge of the correct procedures for safety. Bending cords can cause internal wire damage. Many types of sensitive technical equipment can be damaged if cleaned with soap and water.

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Use of blankets, pillows, and stuffed animals in the crib Explanation: Infant safety education should include use of approved car seats and not booster seats. Booster seats are used for the pre-school child with recommended height and weight. The use of skid-proof mats in the bathtub are topics more suited to the parents of preschool children. Infants are not likely to be physically able to access guns in the home. Infants should not have pillows, stuffed animals, or blankets in the bed due to the risk of suffocation.

There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation?

Use of elevators Explanation: The nurses should avoid the use of elevators in a case of fire. They should not avoid the use of wheelchairs and stretchers, as these can be used to evacuate nonambulatory clients. The nurses should clamp the suction tubes of clients before disconnecting them from the suction apparatus; this helps in transporting the clients faster. The nurses should close doors and windows to reduce the fire's oxygen supply.

A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?

Using carbon monoxide detectors and alarms Explanation: The nurse should suggest the use of carbon monoxide detectors and alarms to prevent carbon monoxide inhalation. Ensuring good ventilation is important at the work place, but it may not be helpful in preventing CO poisoning. The CO gas is odorless; therefore, its presence cannot be detected. Keeping the resuscitation equipment ready is not a preventive measure.

A nurse is assisting a client who has been poisoned. The substance is non-caustic medication. Place the steps the nurse will take in caring for this client in the correct sequence.

Verify that the client is alert. Induce vomiting. Give activated charcoal. Administer a laxative. Explanation: When treating a client who has been poisoned with a product that is not petroleum, caustic, or corrosive, the nurse would (1) verify that the client is alert, (2) induce vomiting, (3) give activated charcoal, and (4) administer a laxative.