Ch 27 - safety, security, and emergency preparedness
The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention?
"I am concerned that the small rugs in your home can be a tripping hazard." Explanation: The nurse can open up the conversation by stating concern about the small rugs. The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"You should never smoke when oxygen is in use." Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.
The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?
A hair dryer is placed next to the sink. Explanation: Electrical shock can result if appliances such as a hair dryer come in contact with water. The hair dryer should be moved away from the sink. Other findings reflect appropriate safety measures
What teaching will the community health nurse include for parents of toddlers?
Household cleaners must be kept out of reach. Explanation: Toddlers are naturally inquisitive and more mobile than infants and fail to understand dangers; therefore, it is appropriate to teach parents of toddlers to keep household cleaners out of reach. Teaching about changing table safety is more appropriate for infants. Teaching about protective sporting gear is appropriate for school-age children who are physically active. Teaching about peer pressure is more appropriate for adolescents.
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact Explanation: Fluids from a draining abscess can transmit infection through contact; therefore contact precautions are appropriate.
The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client?
contact precautions Explanation: Contact precautions should always be used when coming into contact with contaminated body fluids. Gown and gloves should be worn and protective eyewear if splashing may occur. Droplet precautions are used there is a risk of transmitting pathogens within a 3-foot (1-meter) radius of the client when sneezing, coughing, etc. Neutropenic precautions are for the protection of the client due to immunosuppression. Airborne precautions should be instituted when exposure to microorganisms are transmitted by airborne route may occur.
The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?
encourage the colleague to remove the glove by grasping the cuff Explanation: The colleague should grasp the outside of one glove with the opposite gloved hand and peel the glove off, turning it inside out while peeling it off. The glove should not be pulled by the fingers, because this is unlikely to remove the glove and it may snap back. Personal protective equipment should normally be removed while inside the room, and there is no need to maintain a wide distance from the colleague.
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room Explanation: The nurse should intervene if the UAP removes gloves and walks out the room without performing hand hygiene. Personal protective equipment (PPE), including gloves, gowns, masks, and googles, are used as barriers to prevent direct contact with blood, body fluids, secretions, and excretions. PPE is also used to protect clients from microorganisms transmitted by nursing personnel when performing procedures or care. Hand hygiene should be performed before and after wearing gloves and direct contact with clients. Asking the client to state his or her name and date of birth is important to make sure the specimen is collected with the correct laboratory label. To protect the UAP from direct contact with the urine, a face mask is indicated.
Which is not appropriate regarding the use of gowns as PPE?
use of one gown per person per shift Explanation: A new gown should be used by the nurse each time the nurse enters the client's room.
Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?
"Always provide close supervision for young children when they are in or around pools and bathtubs." Explanation: The leading cause of injury and death in children 1 to 4 years of age is drowning. Therefore, providing close supervision when children are in or around tubs and pools will help decrease and/or prevent this injury.
A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?
"Parents are effective role models for children when they also wear helmets while riding." Explanation: Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chin strap should fit snuggly, not loosely. Young children who are secured in a bicycle passenger seat must also wear a helmet.
The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds:
"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." Explanation: Humans are warm-blooded creatures, which means they maintain a consistent internal body temperature independent of the outside environment. The body's surface or skin temperature can vary widely with environmental conditions and physical activity. Despite these fluctuations, the temperature inside the body, the core temperature, remains relatively constant, unless the patient develops a febrile illness.
What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household?
Avoid stuffed animals and blankets in the crib. Explanation: Suffocation is a hazard for infants, especially before the age of 4 months. Toddlers and older children are more at risk for falls, and adolescents tend to engage in risky behaviors. Therefore, education about, and awareness of, these behaviors is important in this age group, but not for an infant. Seat belt safety is more appropriate to teach older children and adults. Car seat safety would be important for families with a newborn infant.
What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?
Centers for Disease Control and Prevention Explanation: The Centers for Disease Control and Prevention (CDC) and the National Safety Council determined that unintentional injuries were the fifth-leading cause of all deaths in the United States in 2009. The American Medical Association and American Nurses Association do not monitor such data. The World Health Organization focuses on global issues and events.
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?
Conceal IV tubing with gauze wrap Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.
When assessing an older adult client's home for safety, the nurse should recommend what?
Eliminating throw rugs Explanation: A study of community-dwelling seniors found that they typically exercised caution by depending on help, restricting activities, eliminating hazards (e.g., throw rugs), and selecting safe spaces. High level of light is beneficial for seniors. There is not a contraindication to taking a tub bath for a senior client as it does not affect safety issues. The senior client should not avoid air conditioning in summer as this can cause an increase in the home and because elderly do not sweat they are at a risk of overheating quickly.
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 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 would be a priority recommendation for this client?
Placing the client in a bed with a bed alarm Explanation: Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.
A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?
Providing prompt recognition of the potential or actual threat to safety Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.
A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?
Pull the fire alarm lever. Explanation: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.
Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?
Social pressure Explanation: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.
The nurse is teaching the caregiver of a 8-month-old infant 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 intervention should the nurse take for a client who is receiving continuous tube feedings?
Elevate the head of the bed at least 30 to 45 degrees to prevent aspiration. Explanation: An elevation of at least 30 to 45 degrees or higher in a client receiving tube feedings will prevent reflux and prevent aspiration. Positioning the client in the supine position for extended periods may lead to aspiration. There is no need to aspirate the contents of the client's stomach after feeding. Coughing and deep breathing do not prevent the tube from being dislodged.
The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the health care provider that a written order is needed. Explanation: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.
What best describes the nurse's role in disaster preparedness?
Multiple roles, including triage and the distribution of resources Explanation: Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
The nurse should question the client about the source of the bruises. Explanation: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.
Which factor is related to the highest proportion of falls in long-term care settings?
Toileting Explanation: More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.
Which level of health care provider may make the decision to apply physical restraints to a client?
nurse practitioner Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.
The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?
Assess the need for assistance with ambulation. Explanation: The diverse physiologic and psychologic capabilities of people and encounters with various safety hazards across the lifespan put various age groups at risk for different safety concerns and potential injuries. Older adult clients are at a higher risk for falling. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom.
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?
The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. Explanation:The nurse should recognize that she lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?
a dose of an antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.
A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?
"I am concerned that the small rugs in your home can be a tripping hazard." Explanation: The nurse can open up the conversation by stating concern about the small rugs. The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?
"I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?
"I will rescue clients from harm before doing anything else." Explanation: The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first.
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?
"Only certain members of the health care team can extinguish a fire." Explanation: All members of the health care team are educated about how to extinguish a fire. Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction. The other statements are appropriate.
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." Explanation: Visitors with respiratory infections need to wear a mask until their symptoms have subsided. The other options do not control transmission of airborne or droplet infections. Hand hygiene is appropriate and should be encouraged but used alone it won't prevent the spread of an airborne or droplet infection.
The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?
19-year-old male college student majoring in physics Explanation: Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.
Which nurse would be at the highest risk of causing a hazardous situation?
A nurse who has worked 32 hours of overtime this week Explanation: Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and be a factor in adverse events. The remaining three scenarios are within the normal realm of practice. A nurse transferring to another unit is able to provide care to clients within the scope of practice; this does not present a hazardous situation. Placing three side rails up assists with prevention of falls and is not classified as a restraint. Administering medications to four clients is an acceptable number of patients to be assigned to administer medications for most clinical settings.
The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?
Activate the fire alarm and notify the appropriate person. Explanation: RACE stands for Rescue - Alarm - Contain - Extinguish. The "A" in the acronym RACE stands for "activate the fire alarm and notify the appropriate person."
The home health nurse is making a home visit for an older adult client recently discharged from the hospital after suffering a stroke. Which finding would most concern the nurse?
Area rugs are present in multiple areas throughout the house. Explanation: An older adult client who recently suffered a stroke is at risk for injury from falls. Living with a family member would likely be an appropriate situation for the client. Medication bottles for an older adult should be kept where they are easy to reach. The medications likely do not have a child-proof safety cap. A house with a basement would not be concerning unless the client must enter the basement and the stairs are unsafe. Area rugs are a tripping hazard for a client who is a fall risk and should be removed.
A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?
Childproofing the house Explanation: To prevent accidental injury and death in toddlers and preschoolers, parents need to childproof the home environment. Play areas should allow for exploration but still provide for safety. Safety equipment for sports should be taught to school-age and older children. Drug and alcohol education is also typical for school-age and older children. Back to sleep guidelines are relevant for neonates unable to roll independently.
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.
Client-centered care Teamwork and collaboration Quality improvement (QI) Explanation: The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.
Which item would alert the home care nurse to a safety hazard threatening a young child?
Dangling blind cords Explanation: As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach.
The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?
Discard the supplies and field and prepare a new sterile field. Explanation: If sterile procedure is disrupted in any way, the nurse must discard all items (including the field) and begin preparing a new sterile field. Reaching over a sterile field would disrupt the sterility of the area. The nurse would not remove the supplies from the field and replace but rather start all over with a sterile field. Education of the client should have been performed prior to the procedure. The nurse should have asked if the client needs anything including a water pitcher prior to the procedure.
A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.
Drowsiness Headache Vomiting Explanation: Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.
The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?
Encourage exercise that improves balance and muscle strength Explanation: Falls are a significant health hazard for the older adult. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. A high-fiber, low-fat diet may be advisable for many older adults, but it is not specific to promoting client safety in the home. Information about promoting regular sleep may improve safety for select groups of clients, but will not have the specific benefits for fall prevention achieved by improved balance and muscle strength. Avoiding liquids before bedtime may decrease the need for night time trips to the bathroom, and may be a valid recommendation for some parties. However, the outcome benefits are not as specific to fall prevention in health older adults as exercise, balance, and muscle strength.
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?
Ensure that two fingers can be inserted between the restraint and the client's extremity. Explanation: Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.
One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?
Implement drowning prevention strategies. Explanation: The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools.
A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.
Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information Explanation: Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?
Initiate use of a bed alarm. Explanation: To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Lock the medications in a cart and finish them upon return. Explanation: Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. The medications should never be left unattended or placed back in their containers. Another nurse cannot administer medications that have been prepared by the first nurse.
A nurse knows that the expression "Do not cause harm" refers to which ethical principle?
Nonmaleficence Explanation: Nonmaleficence is conducting procedures and interventions in a safe manner so that no harm is caused to the client. Justice is the idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society. Fidelity is demonstrated by continuing loyalty and support to a client. Beneficence requires that the procedure be provided with the intent of doing good for the client involved.
A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client?
Note the allergy on the client's record. Explanation: Assessing the client for allergies to medications, food, and latex when in a health care facility is an important task of the nurse. Clearly marking the client's allergies on the client's record will communicate to all health care personnel who interact with the client. It is not the client's responsibility to notify the anesthesiologist; the allergy should be clearly noted on the medical record. Obtaining latex-free gloves for the client's room is an appropriate intervention, but it will not communicate to all hospital staff the client's allergy. Placing a sign on the client's bed will inform bedside caregivers of the allergy, but clearly marking the medical record will inform all health care staff of the client's allergy.
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?
Obtain a three-prong grounded plug adapter. Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.
What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?
Orienting clients to the surroundings decreases the potential for injury. Explanation: Orienting the client to unfamiliar surroundings will decrease the risks for unintentional injury.
The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?
Providing support to abdominal and accessory respiratory muscles Explanation: Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting, in this case with a pillow, supports the incision and surrounding tissues and reduces pain during coughing and deep breathing exercises. While providing emotional support is appropriate, doing so will not affect physiological pain resulting from the intervention. Exhaling with lips pursed increases resistance in the airways, which helps them stay open during exhalation. Supporting the head and shoulders adds to the client's comfort, but doing so does not address the primary source of pain produced by therapeutic coughing and deep breathing.
An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?
Reduce the temperature on the water heater. Explanation: The principles of a safe environment for older adults follow the same general guidelines as those for all ages: comfortable temperature range, adequate clothing, bath water of the right temperature (the setting on the hot water heater may need to be reduced), adequate ventilation, and lighting that allows for safe navigation throughout the house at all times of day. Clients with neuropathy will definitely need the hot water heater temperature reduced.
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?
Refrain from using extension cords. Explanation: Extension cords should not be used so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).
While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?
Report the needlestick to the nurse manager. Explanation: Upon encountering a needlestick, the nurse's priority action is to report the injury. Other actions can take place after the injury has been reported.
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?
Restrain the baby in a car seat. Explanation: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the baby, and keeping all pots and pans in lower cabinets are secondary teachings.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?
Take the restraints off, stay with her, and talk gently to her. Explanation: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.
The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.
Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy Explanation: The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home. The diuretic furosemide may cause the client to fall during frequent and possibly urgent trips to the toilet. Furosemide may also cause volume depletion and dizziness in standing. Diabetic neuropathy contributes to falls because of loss of normal sensation in feet and lower extremities. Consuming alcohol contributes to loss of balance, volume depletion and urinary urgency. Living on one floor and performing regular exercise describe positive characteristics for fall prevention.
A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?
The nurse details the client's response and the examination and treatment of the client after the incident. Explanation: An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions.
The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill?
The nurse researches new technological advances in the treatment of cancer. Explanation: The QSEN definition specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care. QSEN informatics expands the definition of QSEN competencies by calling for the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. Working with the dietitian demonstrates the QSEN teamwork and collaboration competency. Orienting a visually impaired client to his room demonstrates the QSEN safety competency. QSEN competency of client-centered care is illustrated by the nurse working with the client to prioritize care.
The nurse is removing gloves after responding to the call light of a client on airborne precautions. During glove removal, what action is most likely to result in contamination?
The nurse should prevent contamination of the ungloved hand by ensuring there is no contact between the outside of the remaining glove. Grasping and peeling the glove off by the cuff is appropriate and minimizes the risk of contamination.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
The nurse should question the client about the source of the bruises. Explanation: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.
The nurse enters a client's room to administer preoperative antibiotics. Which rights of medication administration must the nurse follow?
Time Explanation: The rights of medication administration include right client, right drug, right route, right dose, right time, right reason, and right documentation. Heart rate, blood type, and room are not included in these rights. Obtaining vital signs may help to determine if a client should be administered the medication, for example, pain medication or blood pressure medications. A client's blood type would not affect medications from being administered. When entering a client's room, the client should self-identify and give the client's birthdate.
Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.
Use a tub/shower seat if balance problems are present. Carefully monitor water temperature. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. Explanation: Several considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using nonskid mats and using a tub/shower seat. Also, care is taken to promote independence by providing the client with long-handled shower brushes or attachments if there is limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. The nurse should use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. The nurse should avoid using perfumed soaps and lotions, as well as avoid rubbing the skin when drying. The nurse should use gentle patting motions to maintain skin integrity.
A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.
Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures. Explanation: Parents should keep identifying information private (e.g., full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything read online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (e.g., .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom
Which type of mobility aid would be most appropriate for a client who has poor balance?
a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?
administration of an antipsychotic agent to alter the client's behavior Explanation: Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Asking the UAP to sit with the client is a diversion method. Articulation of rationale for using a physical restraint is part of nursing teaching.
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne Explanation: Pulmonary tuberculosis is transmitted via airborne mechanisms; therefore airborne contact precautions are appropriate.
The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:
collaborative functioning. Explanation:Nurses manage collaborative problems using both nurse- and physician-prescribed interventions to reduce the risk of complications
When educating families on fire safety, it is important to:
have a meeting place outside the home. Explanation: The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR) Explanation: Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave, so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.
The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?
postural hypotension Explanation: The drop of blood pressure of more than 20 mm Hg between lying and standing, 1 to 2 hours after eating; the report of dizziness; and almost falling indicate the client has possibly developed postural or postprandial hypotension. The other choices may contribute to the situation, but are not the main concern.
Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?
provides slippers for ambulation Explanation: Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls.
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor Explanation: Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter Explanation: Urinary catheters account for the highest percentage (26%) of hospital-associated infections. The four most common types of HAIs are related to invasive devices or surgical procedures: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated events (VAEs). A peripherally inserted catheter is an invasive line. Nasogastric tubes and endotracheal tubes are not associated with HAIs.
The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:
use caution when driving an automobile. Explanation: The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy while driving an automobile. The client is to avoid alcohol, caffeine, and late-night activities.