Chapter 19
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?
"Only certain members of the healthcare team can extinguish a fire."
The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity?
21-year old who cannot eat bananas
A nurse who works with older adults is aware of the high incidence of falls among this population. Which individual exhibits a significant risk factor for falls?
A woman who is prone to episodes of low blood pressure
A nurse is caring for older adult clients. Which is the most important safety issue in older clients?
Accidental falls
A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use?
Alarm activating bracelet
An 18-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:
Automobile accidents
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?
Avoid unattended baths for the toddler.
A nurse has entered the room of a resident at the care facility and discovered that the resident has lit some paper on fire in the trash can. What types of fire extinguisher are appropriate for putting out this fire?
Class A, Class ABC
An unconscious client is brought to the emergency department after ingesting too much prescribed medication. What is the highest priority nursing intervention?
Establish a patent airway
A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority?
Evacuate the client
A nurse on a home visit to a healthy elderly client finds that too much clutter has accumulated in the house. What is the most appropriate nursing diagnosis for the client?
Impaired home maintenanc
A stable client is brought to the emergency department after ingesting too much prescribed medication. What is the highest priority nursing intervention?
Induce vomiting as advised by poison control
A nurse who is a member of a hospital's client safety committee is participating in an initiative to ensure that the institution meets the National Patient Safety Goals. What is the most important way in which this committee can meet these goals?
Institute measures to reduce clients' risks of death and injury while they are receiving care
A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from unintentional poisoning?
Keep cleaning solutions locked up.
A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns?
Keep hot substances away from the baby.
A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?
Obtain a physician's order for restraining from the charge nurse
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.
The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?
Peer pressure causes children of this age to task risks.
The nurse is teaching the caregiver of a 3-year old about safety. Which teaching will the nurse include?
Place all household cleaners out of reach.
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.
A nurse has rushed to the site of an accident where members of a family have suffered carbon monoxide poisoning. What is the highest priority action that must take place during carbon monoxide poisoning?
Remove the individual from the room.
A nurse is preparing discharge teaching for a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?
Restrain the baby in a car seat.
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?
Restrain the client, as he ks harmful to others
In a nursing unit, a physician is about to defibrillate a client. What is an appropriate action when the physician says "clear"?
Step away from the bed
A nurse has been commissioned to ensure that the policies and procedures at a large, multisite health care institution comply with the Nursing Home Reform Law. What trend initially prompted the enactment of this legislation?
The widespread use of physical restraints in long-term care facilities
A nurse is caring for a client who is sensitive to latex. What is the simplest and most appropriate way to avoid exposing the client to latex?
Use nonlatex gloves for the client.
A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety?
area rugs kept on the stairs without carpet
Public health nurses in a community are advocating for new community guidelines to enhance the safety of residents. Residents' risks of accidental asphyxiation can be reduced by which measure?
ensuring that open bodies or water and pools are fenced in