Chapter 25 Safety

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preventive measures can be taken to avoid radiation exposure.

-Lead shielding should be used for patients and staff. -staff should be kept at the farthest distance possible from the radiation source -the length of exposure should be limited. To track exposure and ensure safety - health care professionals working with radiation or radioactive materials should wear a device or badge that is periodically turned in to monitor cumulative radiation exposure levels. -All equipment should be maintained and properly used according to manufacturers' guidelines.

A nurse has a prescription to apply wrist restraints to maintain a client's safety. What should the nurse do when applying this type of restraint? Select all that apply. 1. Check the site of the restraint every 30 minutes. 2. Remove the wrist restraints to provide skin care every 2 hours. 3. Ensure that the wrists are well padded when apply- ing wrist restraints. 4. Permit 3 finger-widths to slide between the client's skin and the restraints. 5. Tie the straps of the wrist restraints to the frame of the bed using a slip knot.

1,2,3,5

A nurse is caring for a client who is hearing impaired and legally blind. What should the nurse do to prevent a sensory deficit? Select all that apply. 1. Encourage the client to wear prescribed hearing aids. 2. Provide a telephone, radio, and talking books. 3. Encourage purchase of a talking watch. 4. Provide a foot bath and back massage. 5. Speak in a high tone of voice

1. . Hearing aids will enhance hearing, which should help prevent the sense of isolation. 2. A telephone, radio, and talking books will help to stimulate the client (e.g., hearing, thinking, socialization). 3. When a button is pushed, a talking watch reports the time. This will help to keep the client oriented to time, which is stimulating. 4. A foot bath and back massage will provide for tactile interaction with the caregiver, increasing stimulation

A community-health nurse is providing a program about fire safety in the home. What recommendations should the nurse include in this program? Select all that apply. 1. Practice a home fire escape plan. 2. Smoke cigarettes in just 1 room of the home. 3. Install smoke alarms near bedrooms and stairs. 4. Install a Class A extinguisher close to the kitchen. 5. Teach participants to stop, drop, and roll if clothing is on fire

1. All residents in a home should develop a home fire escape plan. It includes the number of the local fire department on all phones, routes to take to exit each room of the home safely, and place to meet outside the home after exiting the home 3. A smoke detector near the stairs will detect smoke from a fire as it rises. A smoke detector near bedrooms should alert people who are sleeping because of the close proximity of the alar 5. When a person's clothing is on fire the person should Stop, Drop, and Roll. Stopping limits movement that may fan the flames. Dropping positions the body on the ground in preparation for the next step in the firefighting technique. Rolling helps to deprive the fire of oxygen

A nurse is caring for a 60-year-old adult who is a res- ident in a rehabilitation center recovering from a right-sided brain attack (cerebrovascular accident, stroke). The client has a prescription for out-of-bed ambulating with assistance as tolerated. Which intervention is most important? 1. Assessing balance 2. Using a bed alarm 3. Encouraging the use of a walker 4. Teaching to rise slowly from a sitting to standing position

1. Assessment is the first step of the nursing process. The nurse must first assess the client for the presence of problems with strength and balance before moving a client out of bed. People with problems with balance may not be able to maintain the sitting position while sitting on the side of the bed others are all fall preventions

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

1. The caregiver should walk slightly behind and next to the client being ambulated with a gait belt. This enables the caregiver to hold the belt handle in the center of the back as well as grab the handle on the side if the client needs more assistance with balance. 3. Walking on the client's weaker side provides better support of the client when the client shifts weight to the weaker side when ambulating. 4. Clients who need a gait belt when being ambulated generally have impaired balance or are weak and, there- fore, must be assessed for clinical indicators of activity intolerance. It is not acceptable to just make this assessment after the completion of ambulation. 5. Holding a gait belt at the location of the client's back allows the caregiver to quickly control the client's balance.

An 87-year-old adult is admitted to the hospital for diagnostic tests and intravenous rehydration therapy after a fall in the home. The next day the client's prescription for "out of bed to chair" twice daily was changed to "out of bed ad lib." (AD LIB: Freely, as Desired, if the Patient So Desires) What should the nurse do before getting the client out of bed? 1. Test the strength of the client's legs. 2. Take the blood pressure while the client is supine. 3. Give the client oxygen via a nasal cannula for several minutes. 4. Disconnect the client's intravenous tubing from the venous access device

1. The client's serum sodium (expected range 135 to 145 mEq/L) and potassium (expected range 3.5 to 5.0 mEq/L) are both low, which precipitates muscle weakness. The strength of the client's legs should be assessed to determine if the client can bear the body's weight. While the client is lying in bed, the client can be asked to exert pressure against the nurse's hands that are pressed against the soles of the client's feet. The nurse should assess the strength of the pressure exerted by the client. While the client is sitting on the side of the bed, the client can be instructed to extend the knee of one leg and hold it in extension for 15 seconds. Then the other leg should be assessed in the same manner. If the client can hold the legs in extension, then the client probably has the strength to bear the body's weight

A and a family member arguing with each other in a room at the end of the unit. What should the nurse do first? 1. Get another staff member and go to the room together. 2. Have a security guard handle the situation. 3. Ask what is going on and then set limits. 4. Go to the room and try to intervene

1. The situation needs to be assessed, but a health team member should never enter a volatile situation alone. When entering the room, the health team members should stand between the client/visitor and the door

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

2. Heat causes vasodilation, which increases circulation and capillary permeability in the area; this brings oxygen nutrients, and WBCs to the area and removes toxic wastes.

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

2. Instructing the client how to lock the wheels on a wheelchair allows the client to provide safe self-care when in a wheelchair 4. The ability to call for help when needed gives the client a sense of control. 5. Having an understanding of the environment (e.g., how to use a call bell, how to raise and lower the bed, and how to use the side rails when turning or transferring) gives the client a sense of control

A client who is cognitively impaired is admitted to the hospital for pneumonia. The client has a history of wandering at night. What should the nurse do to meet the needs of this client? Select all that apply. 1. Obtain a sedative to be administered to the client at bedtime. 2. Apply a vest restraint when the client plans to go to sleep. 3. Apply a radio frequency product to the client's wrist. 4. Restrict fluids several hours before bedtime. 5. Activate the bed alarm on the client's bed. 6. Eliminate caffeine products from the diet.

3. A radio frequency product worn on the wrist or ankle or as a pendant alerts the caregiver when a client approaches an area of egress that is unsafe for the client. 4. Restricting fluids several hours before bedtime may reduce the need to void during the night. A cognitively impaired person may feel the need to void during the night and exit the bed to find a bathroom. 5. A bed-exiting device (e.g., position sensor on the leg, weight sensor under the mattress of a bed) should be used to alert caregivers when the client is attempting to exit the bed. A health team member should immediately assist the client and maintain safety when the alarm sounds. 6. Caffeine is a stimulant. Removing caffeine products from the diet may help reduce wandering at night

A for a vest restraint. Which actions should the nurse implement? Select all that apply. 1. Check the restraint every 2 hours. 2. Release the restraint every 4 hours. 3. Tie the restraint to the movable part of the bed frame. 4. Provide skin care every 3 hours when a client has a restraint. 5. Ensure that the cross-over of the vest restraint is in the front of the client.

3. A vest restraint should be tied to the movable part of the bed frame. If the restraint is tied to the immovable part of the bedframe, the client may be injured or the restraint may become too tight and impair respirations when the head of the bed is raised. If the head of the bed is lowered, the restraint will become too loose. 5. The cross-over of a vest restraint should be in the front of the client, not the back. If the vest was applied with the cross-over in the back and the client should slide down in the bed, the collar edge could choke the client

A nurse just finished a complete bath for a client with limited mobility. Which action is most important for the nurse to perform before leaving the bedside of the client? 1. Raise all of the bedside rails. 2. Ensure that the water pitcher has fresh water. 3. Lower the height of the bed to the lowest position. 4. Position the bedpan in easy reach under the covers.

3. All clients should have their beds maintained in the lowest position unless a member of the health-care team is providing direct care. This supports client safety. It enables mobile clients to more easily enter and exit the bed. Also, if a client should fall out of bed accidentally, the bed is closer to the floor, which may minimize client injury.

The nurse is discussing serious reportable events related to patient safety with student nurses. Which environmental events would be discussed? Select all that apply. a. Physical assault with the patient b. Patient death due to burns from facility equipment c. Patient death associated with falls d. Sexual assault with the patient e. Patient death due to electrocution

b,c,e a& d are criminal reports

A nurse is caring for an older adult who is cognitively impaired and has a history of pulling out tubes and falling. List the following safety devices in the order of least restrictive to most restrictive that may be employed to ensure the safety of this client. 1. Cloth vest 2. Two wrist straps 3. Four side rails up 4. Bed exiting alarm device 5. Four-point restraint tied to the bed frame

4. A bed-exiting alarm device will signal caregivers when the client attempts to exit the bed. These devices do not restrict the client's movement but will alert staff members that the client needs supervision. This is a safety device that does not require a prescription from a primary health-care provider. 3. Although four side rails will confine the client to the bed, the client is still able to turn and sit up with ease. 1. A cloth vest permits turning from side to side and sit- ting up but physically restricts the client to the bed by the use of straps tied to the bed frame. 2. Two wrist restraints restrict the movement of the upper extremities and prevent turning from side to side; also, they confine the client to the bed because the straps are tied to the bed frame. 5. A four-point restraint is the most restrictive physical restraint because the extremities are for all practical pur- poses immobilized; all four extremities are tied to the bed frame.

A client who is legally blind says to the nurse," I once was able to see a little bit, but now I can't see anything." What should the nurse encourage the client to do while hospitalized? 1. Wear dark-tinted eyeglasses. 2. Keep a light on in the room at all times. 3. Close the window blinds during the day. 4. Call for assistance when getting out of bed.

4. A client who is in a strange environment and who has a visual impairment is at an increased risk for falls. The client should seek assistance with transfers and ambulat- ing until the client feels comfortable engaging in these activities and the nurse determines that the client is safe to perform this activity unassisted.

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

4. A lead apron provides a barrier between the nurse and the source of the radiation; it adheres to the principle of shielding. 5. Thirty-minute visits daily and sitting by the door protect a visitor from excessive exposure to radiation emanating from the client; these parameters follow the principles of time and distance. 6. All soiled linen should be held in the room until surveyed by radiation safety staff. This ensures that linen is safe for removal from the room

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

4. Assessment is the first step in the nursing process. As- sessments should be completed before planning and implementing care. Older adults often experience one or more chronic illness and receive a variety of medications. Polypharmacy is a risk factor for adverse reactions and drug interactions that may cause an older adult to fall.

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

4. Spreading the legs of the lift apart widens the base of support increasing stability of the lift. 5. Attaching the longer straps to the lower grommets in each side of the sling is correct. When the longer straps are attached to the bottom of the sling and the shorter straps are attached to the top of the sling, the client will be raised to a sitting position when the lift raises the sling and the client up and off the bed.

Drowning is the major cause of suffocation death in _____ who do not take appropriate safety measures while swimming.

adults

the nurse is performing a falll risk assessment on a newly admitted patient. Which finding is a greater known risk factors for falls? a. taking aspirin b. urinary incontinence c. multiple comorbidites d. malnutrition

Urinary incontinence a known factor that increases fall risk, is included on the Johns Hopkins Hospital Fall Assessment Tool and Hendrich II Fall Risk Model.

the nurse is aware that parents are being safety advocates when they do which of the following? a. keep a rear facing car seat until the child is at least 12 months old b. limit amount of tv of children to 3 to 4 hours c. asks the teen to turn the headphone volume down when the music is audible to others. d. avoid panting in house unless the temp is above 60 degrees

Using earphones while listening to loud music can cause permanent hearing damage. The level of the music should be no louder than normal conversation to be considered safe, so being able to hear it audibly by others means it is too loud and volume should be reduced. Infants and toddlers should be rear facing until they are at least 2 years old or reach the highest weight or height allowed by the car seat manufacturer. School-age children should be limited to no more than 2 hours per day of sedentary screen time

In _____, the leading causes of death by suffocation are cosleeping and the use of pillows and blankets.

infants

Which group has the highest risk of death due to suffocation caused by choking on foreign objects? Adults Infants Toddlers Older adults

infants

In _____ people, death can occur from choking on food lodged in the trachea.

older

During seizures, the patient may choke due to pooling of secretions that may obstruct the airway. To ensure a patent airway, the patient should be turned to _____ _____ so that the tongue does not interrupt the airway. Tilting the head slightly ______ helps in free drainage of saliva.

one side, forward


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