Chapter 10 - Safety

When caring for the patient who required the use of a SRD, what should be included in the patient's plan of care? (select all that apply) 1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 3. Secure the ends of the ties to the side rails 4. Ensure that the SRD is in place at all times 5. Reevaluate the need for the SRD frequency

1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 5. Reevaluate the need for SRD frequency

The patient reports dizziness when standing up too fast. Which over-the-counter medications is most likely to be contributing to the patient's orthostatic hypotension? 1. Nonaspirin pain reliever 2. Antihistamine 3. Vitamin supplement 4. Medicated cough drp[

2. Antihistamine Antihistamines cause drowsiness and have mild sedative properties, so patients should be cautioned about side effects.

What is the most common problem that nurses need to address to ensure the safety of their patients? 1. call light not in reach of the patient 2. percentage of falls in the facility 3. patients who are violent 4. side rails not in the upright position

2. Percentage of falls in the facility

A 63 year old man is brought to the emergency department for treatment of unintentional poisoning. What is the nurse's first action in caring for this patient? 1. Induce vomiting 2. Assess the patient 3. Place the patient in an upright position 4. Notify the poison control center

2. Assess the patient

The LPN is caring for a patient who has a safety reminder device (SRD). What are the most appropriate points that need to be included in the documentation? (select all that apply) 1. Reason for the physical restraint 2. Explanation given to the patient and family 3. Presence of a family member or representative 4. Duration of the use of the physical restraint 5. Type of safety reminder used

1, 2, 4, 5. Appropriate points to be included in documentation of a patient with an SRD include the type of restraint device, the reason for the physical restraint, an explanation given to the patient and family, the date and time of the patient's response to the treatment, duration of the use of the physical restraint, frequency of observation and the patient's responses, safety (including release of the patient, exercise, and assessment of circulation and skin integrity), assessment for the continued need for the physical restraint, and patient outcomes. Although the patient's family needs to be informed of the use of restraints and the reasons for them, it is not required that a family member or representative be present.

The nurse is planning to teach a community group about fire safety in the home. What information should be included in the presentation? (select all that apply) 1. No smoking by the patient, family, or visitors in area where oxygen is used 2. Use safety matches to light candles or fire places 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills 5. Use one electrical circuit to facilitate monitoring of cords and appliances 6. Cover electrical cords with a secure carpet to prevent falls

1, 3, 4 1. No smoking by the patient, family, or visitors in area where oxygen is used 2. Use safety matches to light candles or fire places 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills No one should smoke around oxygen. Fire alarms and other detectors should be properly installed and routinely checked. Family should have escape routes planned and practiced. Use of candles should not be encouraged. Using one electrical circuit creates a potential for overload. Covering electrical cords may decrease falls, but the carpet will mask frayed cords and offer a fuel source for fires.

The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What should the nurse do first? 1. Seek assistance to move the patient and the ventilator to safety 2. Turn off oxygen supply and provide manual respiratory support 3. Close the patient's door, call 911, and fight the fire in the corridor 4. Delegate the UAP to move ambulatory patients toward the exit

4. Delegate the UAP to move ambulatory patients towards the exit. By delegating the UAP to move the ambulatory patients, the nurse is rescuing the greatest number. Next, the nurse would call 911. Closing the door is appropriate because the door will block the smoke and the fire. The nurse must then attend to the helpless ventilator patient. Oxygen creates a good environment for a hotter and faster fire, so oxygen is turned off. The nurse now has to manually support respiration by delivering breaths with a bag-valve-mask or a pocket mask. Both methods will be delivering room air. The nurse is aware that moving the patient and equipment would take a minimum of 2 people and this action would also partially block the hallways; thus the nurse would use critical thinking to determine when (or if) to move the patient.

An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD

4. Right elbow SRD The infant is using his right hand to grab the dressing on the left arm. If the right elbow is secured in a straight position, he shouldn't be able to reach the dressing. (Note - sometimes it may be necessary to pin or secure the SRD to the linen/mattress if the child is very determined.) Mummy wrap is more restrictive and usually used as a temporary restraint during procedures. Bilateral wrist SRDs are also more restrictive and the infant is likely to have skin damage because he will continuously pull to get free. The wrap jacket allows free arm movement.

Which instructions should be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation? 1. Do not go into the room unless the patient uses the call bell 2. Help children to don a lead shield apron before entering the room 3. Wear a mask, eye shield, and isolation gown when entering the room 4. Wear your dosimeter during patient care or when handling patient items

4. Wear your dosimeter during patient care of when handling patient items. Anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter. This includes handling items such as linen and trash. Routine care must continue (ex vital signs and hygiene); thus staff will enter the room whenever necessary, but care should be well-organized so that minimal exposure occurs. Children under the age of 18 should not visit the patient while there is danger of radiation exposure. Wearing a mask, eye shield, and isolation gown do not offer sufficient protection against radiation exposure

The nurse is conducting a fall risk assessment on an elderly patient who is moving into an assisted-living center. Which question(s) would the nurse ask? (select all that apply) 1. Have you had any falls in the past year? 2. Are you able to independently get up after a fall? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 5. Have you ever lost consciousness after a fall? 6. Do you use a cane or other assistive device?

1, 3, 4, 6 1. Have you had any falls in the past year? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 6. Do you use a cane or other assistive device? Previous history of falls and unsteadiness increase the risk for falls. If assistance is required to walk from room to room, the nurse must plan to assist the patient to the bathroom and meals. The nurse ensures that all assistive devices are close to the bed or chair. Asking the patient if he can independently get up after a fall is an assessment of strength and independence, but this also suggests that the patient should independently attempt to get up after a fall. (Patient should be assessed for injury after a fall and encouraged to regain balance and strength before attempting to get up.) Assessing for loss of consciousness is usually performed when trying to determine the etiology of the fall (ex. head injury, neurologic event, cardiac event.)

The patient is using an older thermometer at home that contains mercury. The thermometer is dropped and breaks, releasing mercury onto the floor. What is the priority nursing action? 1. Evacuate everyone from the room 2. Close the interior doors and open windows. 3. Vacuum the mercury and the glass shards 4. Mop the floor with hot water and soap

1. Evacuate everyone from the room Everyone should leave the room where the thermometer has been broken. Close interior doors and open windows to increase ventilation to the outside. The area should not be vacuumed, but should be moped with a mercury-specific cleansing agent. The home health nurse should refer to agency policy for additional directions that relate to the home environment.

A newly admitted patient appears to be disoriented and the nurse is considering using a safety reminder device (SRD). What is the nurse's next intervention for this patient? 1. Obtain a physician's order 2. Discuss the matter with the family 3. Place the safety device on the patient's consent 4. Alert the staff about the patient's confusion

1. Obtain a physician's order Most facilities have specific policies regarding the use of a safety reminder device and require a specific physicians order to implement this intervention. The family and staff need to be informed of the use of a restraint. Although the family needs to be informed of the use of restraints, their consent is not required. The patient's consent is not required for use of restraints in this circumstance. Although the staff needs to be informed of the use of restraints of a patient, their consent is not required.

The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. Which laboratory value would the nurse check first? 1. Red blood cell count 2. White blood cell count 3. Blood urea nitrogen 4. Creatinine level

1. Red blood cell count Postoperative patients have a risk for blood loss, and anemia can cause dizziness and shortness of breath. An infection would cause an increased whit cell count; dizziness and shortness of breath may accompany infection, but these would not be the most typical symptoms. Blood urea nitrogen (BUN) and creatinine reflect kidney function; however, changes in BUN and creatinine can occur and the patient would not show immediate symptoms.

A patient has had a wrist safety reminder device on for the last 2 hours. What is the nurse's highest priority intervention? 1. Remove the safety reminder device and assess circulation and skin integrity 2. Make sure the safety reminder devices are fastened securely 3. Assess the patient's orientation for improvements 4. Loosen the safety reminder device, but do not remove them until ordered

1. Remove the safety reminder device and assess circulation and skin integrity When physical safety reminder devices are being used on a patient, it is important to remove them at least every 2 hours and assess the area for proper circulation and for any impairment in skin integrity. The others are not appropriate interventions for a patient who has been in restraints 2 hours.

An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. The nurse intervenes by: 1. obtaining an order for a bed and chair alarm 2. keeping the light on and the television playing all night 3. putting up the side rails and frequently checking on the patient 4. having the family come to check on the patient at night

1. obtaining an order for a bed and chair alarm A bed and chair alarm alert the nursing staff that the patient is getting up, so someone knows to go assist the patient. Keeping the light and television on would add to confusion and disorientation. Side rails are considered a form of restraint and confused patients often attempt to crawl over the rails. Frequently checking on the patient is always a good idea, but the patient can still wander off between times. Having family come in every night is unpractical and unrealistic in an extended care situation.

What are some safety considerations a nurse should contemplate when caring for an older adult? 1. they are old and frail 2. they are bitter and take a lot of medications 3. Their visual acuity is not good, and their reflexes are slow 4. They are concerned about their finances and what this hospitalization will cost them

1. they are old and frail

The nurse is reviewing the disaster preparedness plan for a small nursing home. What should be included in the plan? (select all that apply) 1. Emergency treatment for the most critically injured 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 5. Designation of an area for decontamination 6. Method of patient identification, such as patient bracelet or picture ID

2, 3, 4, 6 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 6. Method of patient identification, such as patient bracelet or picture ID For nursing hoes or long term care facilities, the plan must include ways to keep track of residents and notification of families and health care providers. The goal would be to provide a safe environment, which may include moving residents to another location. Providing emergency treatment for critically injured patients or initiating decontamination would be included in hospital disaster plans.

A nurse is working in a long term care facility caring for older adults. What type of accident is most often experienced by an older adult? 1. Burns 2. Falls 3. Poisoning 4. Asphyxiation

2. Falls Due to physiologic changes that older adults experience, they are at risk for falls. Most falls occus when transferring to a bedside commode or wheelchair. The most common accident experience by an older adult is related to the physiologic changes of aging, such as loss of vision and balance

A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern? 1. Hives 2. Laryngeal edema 3. Runny eyes and nose 4. Localized swelling

2. Laryngeal edema Laryngeal edema puts the patient at risk for an airway obstruction. The other signs and symptoms could occur during a type IV hypersensitivity allergic reaction which is less serious.

A mother brings her alert and playful child to the clinic because she "found him playing with an empty bottle of baby aspirin". Which question is most important to ask the mother? 1."Has he ever done anything like this before?" 2."How many times has he vomited since the ingestion?" 3."How many pills do you think were in the container?" 4."Did you contact poison control before you drove to the clinic?"

3. "How many pills do you think were in the container" In cases of overdose, it is essential to determine the quantity. The mother may need help to remember that the bottle was half full, or only had 2 or 3 pills. In the case of aspirin, the number of times of vomiting is less relevant, because aspirin is readily dissolved and absorbed in the stomach. The health care team will contact Poison Control regardless of the mother's first report or the first aid given at home. In addition, Poison control is likely to have the mother's call on file. Asking about previous episodes of poisoning would be relevant after current emergency care is given, if the health care team has reason to suspect child neglect/abuse.

Which occurrence is most likely to be investigated as a "sentinel event"? 1. Patient leaves the hospital against medical advice because she gets angry with the nurse. 2. An older patient sustains a broken arm related to the use of an SRD 3. A nurse is 2 hours late administering routine scheduled medications 4. During a follow-up phone call, a patient reports that care in the hospital was poor.

3. A nurse is 2 hours late administering routine scheduled medications. A sentinel event is an occurrence that causes death or serious injury. A broken arm suggests that there may have been improper assessment, application, monitoring, or choice of SRD. The other events may be subject to an internal review by risk management, hospital administration, or the nurse manager.

The nurse is giving instructions to the UAP about patient safety and fall prevention. What should the nurse tell the UAP about helping the patient go to the bathroom? 1. Help the patient whenever she needs help 2. Ask her if she wants to walk or use the bedpan 3. Have her sit up slowly and dangle her legs before standing 4, Help her to the commode chair if she seems weak

3. Have her sit up slowly and dangle her legs before standing. The nurse gives specific measures to prevent orthostatic hypotension (ex. sit slowly and dangle the legs before standing). "Whenever she needs help" is a vague direction that requires the patient to ask for help and then the UAP must decide if help is appropriate, but there is no guidance about circumstance or execution. The nurse should assess whether the use of the bedpan is appropriate for the patient. If the patient is able to get up, walking decreases the complications of immobility. The UAP should not be expected to make a decision about "if she seems weak." This decision should be based on nursing assessment.

The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother? 1. What to do when using pots and pans on the stove 2. How to ensure backyard pool safety measures 3. How to manage electrical sockets and cords 4. where to obtain safety labels for cleaning products

3. How to manage electrical sockets and cords For infants who are just learning to crawl, the mother should look at what's on the floor and within arm's reach from a crawling position. This would include electrical sockets and cords. Pots and pan handles should be turned away from the child's reach. This becomes relevant when the child begins to stand and walk. Pool safety is more related to toddlers and children. Children can be taught to recognize dangerous products, but this is for preschoolers who have developed language skills.

The nurse started a new job in a small LTC facility in a rural area. The back exit hallway is being used as a storage area and "a new storage area is being planned." What should the nurse do first? 1. Report the facility for unsafe conditions 2. Express unwillingness to work in unsafe conditions 3. Review the facility's policies/procedures for emergencies 4. Check the building for other safety issues

3. Review the facility's policies/procedures for emergencies The nurse would first review the facility's emergency/fire policies and procedures to determine if contingency plans have been made for the blocked hallway. Based on the review of the policies/procedures, the nurse may decide to use the other options.

The LPN/LVN is reviewing the admission information of a patient. Which information is of most concern to he nurse that this patient is at high risk for falling? 1. The patient has diabetes 2. The patient had a stroke 3 years ago with no complications 3. The patient becomes disoriented in the evening hours 4. The patient wears eyeglasses and a hearing aid

3. The patient becomes disoriented in the evening hours

A male patient of average build requires assistance to ambulate down the hall. He has some weakness on the left side. The nurse assists this patient to ambulate by applying a gait belt and standing at his: 1. left side and holding the weak left arm 2. right side and holding the front of the gait belt 3. left side and holding the back of the gait belt 4. right side and holding one arm around his waist

3. left side and holding the back of the gait belt The nurse stands on the WEAKER side and grasps the gait belt at the back. This position allows the nurse to provide support and ease the patient to the floor if he begins to fall.

The nurse is providing home poison control instruction to the parent of a 2-year-old boy. Which statement by the parent indicated the need for further teaching? 1. "I will call the national poison control center if my child ingests a poisonous substance." 2. "I will call 911 immediately if my child ingests medication that is not intended for him." 3. "Child safety caps on household cleaner can still be opened by some children." 4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

What type of problem is a major concern for older adults? (select all that apply) 1. Driving 2. Hospitalizations 3. Accidental poisoning 4. lonliness

1, 2, 3, 4,

Why should a hospital have a disaster plan? 1. to be prepared in times of emergent community situations with the possibility of a large number of casualties 2. To be familiar with possible emergent situations that could affect a community 3. To eliminate factors that could cause a community disaster 4. To fulfill federal guidelines that pertain to hospitals

1. to be prepared in times of emergent community situations with the possibility of a large number of casualties

The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct? 1. The nurse cleans the mercury spill with alcohol and ordinary cleaning cloths 2. The nurse closes all windows and doors to prevent the mercury spill from spreading out of the area 3. The nurse instructs housekeeping staff to vacuum up the spill 4. The nurse evacuates the area and contacts trained personnel to clean up the spill.

4. The nurse evacuated the area and contacts trained personnel to clean up the spill.

OSHA

Occupational Safety and Health Administration

Type A fire extinguisher used for

Paper, wood and cloth fires

True or false: Electrical accidents are often prevented by reporting frayed or broken electrical cords or any shocks felt when using equipment

True

True or false: It is acceptable to delegate monitoring patient behavior for risk and injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff

True

True or false: It is acceptable to delegate monitoring patient behavior for risk for injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff.

True

The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries? 1. Gender of the child 2. Overall health 3. Education level 4. Developmental level

4. Developmental level

True or false: Growth and the acquisition of new motor skills place children at an increased risk for injury

True

What type of sensitivity is often seen in the health care environment? 1. Allergic reactions to disinfecting chemicals 2. Reactions to airborne diseases 3. Latex allergies 4. Vinyl allergies

3. Latex allergies

What national organization provides guidelines to protect health care workers in their environment? 1. National Institutes of Health 2. National Alliance for Health Care Providers 3. National League of Nurses 4. Occupational Safety and Health Administration

4. Occupational Safety and Health Administration

The nurse is considering the use of an SRD to prevent a patient from self injury. When using an SRD, the nurse should: (select all that apply.) 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 4. obtain consensus of nursing staff for type of SRD 5. exhaust all alternatives before using an SRD

1, 2, 3, 5, 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 5. exhaust all alternatives before using an SRD The use of SRDs requires an order, explanation to the patient and family, and is only used as a last resort after other methods have been tried or considered. The entire nursing staff does not have to be consulted about the type of SRD. Type of SRD depends on provider's orders, clinical judgment, and ongoing assessment.

During the 7am to 3pm shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation? 1. A school bus accident 2. A bomb threat in the mail room 3. A hostage event in the emergency department 4. An electrical fire in the maintenance department

1. A school bus accident

A patient begins to have a grand mal seizure. Which action should be delegated to the UAP? 1. Ensure that the tongue is not occluding the airway 2. Place pillows or other soft materials on side rails 3. suction the mouth for frothy secretions to prevent aspiration 4. Gently insert an oral airway between the teeth

2. Place pillows or other soft materials on side rails If the patient is having uncontrollable movements during a grand mal seizure, placing soft material against the side rails offers some protection. Checking the airway and suctioning secretions should be performed by the nurse. Inserting an oral airway is not done during the seizure, but may be done after the seizure is over to keep the tongue from falling backward; also there is always a possibility of a repeat seizure until medication or other therapy is given.

Before the nurse can intervene, a UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What should the nurse do first? 1. Tell the UAP to immediately report to the infection-control nurse 2. Assist the UAP to scrub the wound with copious amounts of soap and water 3. Report the UAP for improper handling of hazardous material 4. Dispose of the sharps container to prevent any additional injuries to others.

2. Assist the UAP to scrub the wound with copious amounts of soap and water. Scrubbing and flushing the wound with soap and water is the best first measure to decrease risk of infection. The UAP should contact the infection-control nurse. Sharps boxes should never be overfilled, but are disposed of before they are full and immediately replaced. The nurse and the UAP should both write an incident report which would include the facts.

The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation? 1. The nurse's feelings about having used the SRD 2. The specific type of SRD used 3. Confirmation of a prn order for use of SRD 4. Evidence that the patient was assessed every 8 hours

2. The specific type of SRD used

The nurse working in a local health department knows that a bioterrorist attack that can occur via the food-borne route is: 1. anthrax 2. botulism 3. plague 4. smallpox

2. botulism Botulis can be transmitted by contaminated food. Inhalation is the most likely form of anthrax as a bioterrorist weapon. A bioterrorism-related outbreak of pneumonic plague is likely to be airborne and can spread among people via large aerosol droplets. Smallpox can be transmitted by contact or by the airborne route.

Which new equipment creates the greatest risk for falls for an older adult? 1. Wheelchair 2. Prescription lenses 3. safety bar in shower 4. walker

2. prescription lenses Any new device or equipment has some risks because of the learning curve; however, new prescription lenses frequently cause some distortion in depth perception and they are less likely to be perceived by the patient or the staff as "new" or directly related to safe ambulation. A wheelchair, safety bar, and walker are designed to increase stability. In addition, the elderly adult is likely to approach these new items with caution.

While reviewing fire safety, a type C fire extinguisher can only be used on which type of fire? 1. A fire cause by a flammable liquid 2. An electrical fire 3. Paper, wood, or cloth fire 4. Any type of fire

2. An electrical fire A type C fire extinguisher is used for electrical fires. A type B fire extinguisher is used for flammable liquid fires. A type A fire extinguisher is used on paper, wood, or cloth fires. An ABC fire extinguisher is used on any type of fire.

The nurse notices smoke coming from the wastebasket in a patient's room. Upon entering the room, the nurse sees a fire that is starting to flare up. What should the nurse do first? 1. Extinguish the fire 2. remove the patient from the room 3. close the door to the room 4. turn of all electrical equipment

2. remove the patient from the room The nurse remembers RACE and first removes the patient from the room. As they exit the room, the nurse closes the door to confine the fire to that room and then sounds the alarm. The nurse is not likely to turn off all electrical equipment in this case.

When assessing a patient's knowledge of the fire safety precautions, which action indicated the need for further fire safety instruction? 1. fire exits and corridors are kept clear 2. A no smoking sign is posted when oxygen is in use 3. A heating pad cord is taped when a frayed area is noted 4. Facility smoking policies are a part of the admission procedure

3. A heating pad cord is taped when a frayed area is noted

The nurse is caring for a patient on a ventilator and reads the order "restraint prn." The nurse considers which factor when caring for this patient? 1. SRDs often decrease anxiety because the patient feels safer 2. All older adult patients need some type of SRD at night 3. Allow as much freedom of movement as possible when applying SRDs 4. When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail

3. Allow as much freedom of movement as possible when applying SRDs

For the care of a patient who has an SRD in place, which task can be delegated to a UAP? 1. Observe for circulation distal to the SRD 2. Check for respiratory effort and breathing 3. Change position every 2 hours 4. Determine when the SRD can be removed

3. Change position every 2 hours The UAP can be instructed to assist the patient to change position every 2 hours. Assessment of circulation and respiratory effort should be performed by the nurse. The RN and health care provider should be consulted to determine the time for removal of SRDs.

It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom? 1. Erratic behavior 2. Nausea and vomiting 3. Respiratory distress 4. Vesicle formation

3. Respiratory distress Severe respiratory distress is the most prominent symptom of cyanide gas exposure.

Which newly admitted patient would be at the greatest risk for an injury? 1. An 80-year old patient 2. A patient who wears corrective lenses 3. A patient who has arthritis 4. A patient who has a history of falls

4. A patient who has a history of falls All of these patients are at risk, but the patient who has a history of falls is at the highest risk to sustain an injury; possibly from another fall

In the event of a bioterrorist attack, what is the first role that the nurse must perform? 1. Isolate suspected cases 2. Advocate for public safety 3. Liaison with the public health department 4. Recognize high-risk syndromes

4. Recognize high-risk syndromes Before any action is taken, someone must recognize that an unusual biologic event is occurring. The nurse is one of the first health care professionals who will assess patients for flulike symptoms or other symptoms that mimic endemic disorders. The nurse would isolate any suspected cases and immediately contact the supervisor, so that emergency/disaster plan can be activated. The plan should include notification of the local public health department and attention to public safety.

CDC

Center for Disease Control and Prevention

Type B fire extinguisher used for

flammable liquid fires, such as those caused by anesthetics

Type C fire extinguisher

electrical fires

latex type I sensitivity

A true latex that is possibly life threatening. Reactions are likely based on type of latex protein and degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest

latex type IV sensitivity

Cell-mediated allergic reaction to chemicals used in latex processing. Delayed reaction, including redness, itching and hives, up to 48 hours is possible. Localized swelling, red and itchy or runny eyes and nose, and coughing often develop

True or False: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury.

False. There is a 0.03% chance of a health care worker becoming infected with HIV from a sharps injury

True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities

False. They are used in many health care facilities, and most LTCs are eventually adopting a restraint free environment

Factors that influence the safety of the older adult in the home or health care environment

changes in sensory function (vision, hearing, touch), decreased muscle strength, decreased circulation, medications taken, and possible cognitive alterations

The LPN is reinforcing discharge teaching with parents for a small child regarding poisoning. Which statement by the parents would indicate the need for further teaching? 1. "we're going to install child-resistant laches on all the cupboard doors." 2. "we have some empty food containers that we can use for storing anything dangerous." 3. "At the pharmacy, we will ask for child-proof lids on all prescriptions." 4. "We're going to move all the plants out of read or outside."

2. "we have some empty food containers that we can use for storing anything dangerous." Toxic substances should never be stored in food containers, but in their original containers that are labeled. In a food container, the substance may be thought of as food. The other statements indicate appropriate courses of action for preventing future poisinings.

The LPN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the best goal for this patient? 1. Patient will remain free of injury 2. Patient will allow SRDs to be used 3. Nurse will check SRD every 30 minutes 4. Use least restrictive form of SRD possible

1. Patient will remain free of injury

The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicated to the nurse that further instruction is necessary? 1. The UAP loosely fastens the gait belt around the patient's waist 2. The UAP places the gait belt on the resident before assisting the resident to a standing position 3. The UAP grasps the gait belt while assisting the resident out of bed 4, The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair 5. The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation

1. The UAP loosely fastens the gait belt around the patient's waist 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair

The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing this patient's home environment? 1. Accidental poisoning 2. Electric shock 3. Accidental falls 4. Thermal burns

3. Accidental falls

RACE

Rescue patients sound the Alarm Confine the fire Extinguish/Evacuate

A patient has a care plan with a nursing diagnosis of Risk for Injury. Which interventions would be the most appropriate? (Select all that apply.) 1. Keep bed in low position except when care is given 2. Instruct the use of a call bell and keep in reach at all times 3. Orient patient to the room and environment to provide familiarity 4. Allow patient to have reading materials and clothing lying about the room 5. Assist the patient to the bathroom frequently

1, 2, 3, 5. Each of these interventions is necessary and appropriate to reduce the risk of injury. Allowing the patient to have reading materials and clothing lying about the room is innappropriate because the environment needs to be free of litter to reduce the risk of tripping and falling.

What does universal carry mean? 1. How to remove a patient from the bed to the floor 2. How to carry a patient as if he/she were an infant 3. How to carry two patients at one time 4. How to evacuate several patients in a short amount of time

1. How to remove a patient from the bed to the floor

True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities.

False. SRDs can be used in any health care setting. Many long term care facilities are currently adopting a restraint-free environment

True or false: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury

False. There is a .03% chance of a health care worker becoming infected with HIV from a sharps injury