Chapter 27: Safety, Security, and Emergency Preparedness
The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action? Remind the client that oranges and spinach can cause a cross-reaction. Keep balloons on the opposite side of the client's room. Assure the client that balloons do not cause breathing difficulties. Replace common health care items with latex-free equipment.
Replace common health care items with latex-free equipment. Explanation: The client has described a reaction to latex, so the environment should be as free from latex as possible. The nurse will replace all health care equipment with latex-free versions. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes, not oranges and spinach.
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 a geriatric chair with a tray a dose of an analgesic side rails
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 client arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action? Identify chemical agent before treating Assess client's respiratory depth and effort Activate external disaster protocol Flush skin while rinsing with sterile saline
Activate external disaster protocol Explanation: Before performing assessments or interventions, it is essential that the nurse inform others about the incident in order to mobilize assistance. In most cases, this involves the activation of an emergency protocol.
The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention? Apply an allergy-alert identification bracelet on the client. Flag the room door. Teach the client to wear a Medic-Alert bracelet. Notify the interdisciplinary health care team to use nonlatex equipment.
Apply an allergy-alert identification bracelet on the client. Explanation: The priority is to apply an allergy-alert bracelet to the client so that any member of the interdisciplinary team can quickly identify the latex allergy. All other actions can take place immediately thereafter.
The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Nothing, as it is none of the nurse's concern. Ask to examine the client alone in order to speak to her privately. Report the suspicions to to the authorities. Document the observed behaviors in the client's chart.
Ask to examine the client alone in order to speak to her privately. Explanation: In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.
A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? Assessment of vital signs and respiratory status Evaluation of all of his cranial nerves Initiation of a peripheral intravenous (IV) line for fluid administration Assessment of head circumference
Assessment of vital signs and respiratory status Explanation: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.
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? Allow the child to swim with friends. Avoid unattended baths for the toddler. Instruct the toddler not to go near the pool. Monitor the activities of the toddler.
Avoid unattended baths for the toddler. Explanation: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.
The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action? Prepare the medication for administration. Repeat or read back the order. Document the order in the electronic health record (EHR). Identify the client by last name and date of birth.
Repeat or read back the order. Explanation: In keeping with National Patient Safety Goals, the nurse will read back the order, then proceed to document the order in the EHR, prepare the medication, and identify the client by two identifiers prior to administration.
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? The hospital will be fined by CMS because the client developed a pressure injury. CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future. The hospital must bear any costs incurred for treating the client's injury.
The hospital must bear any costs incurred for treating the client's injury. Explanation: If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.
The nurses on a critical care unit can utilize the safety strategy of redundancy by: introducing a brief waiting period between the time that a medication is ordered and the time that it is administered. having two nurses independently check the dosage of high-risk medications. introducing equipment that makes it more difficult for a nurse to commit an error. ensuring the antidotes are readily available for certain high-risk medications.
having two nurses independently check the dosage of high-risk medications. Explanation: Intentional, successive checks for certain high risk procedures or events add needed safety redundancy. For example, two registered nurses check the information about the client, and about a blood product about to be administered, to ensure the blood product is the correct one and is safe for the client. The use of antidotes and waiting periods is unrelated to redundancy. Equipment that makes it difficult to commit an error is an example of mistake-proofing.
A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized? reinforcing the standards for nursing care to staff members who were involved ensuring that the client's nurse is held accountable and educated about best practice identifying systemic factors on the unit that may have contributed to the event communicating the potential consequences of the near miss to the client involved
identifying systemic factors on the unit that may have contributed to the event Explanation: Central to creating a culture of safety is the need to identify systemic factors that may contribute to errors or near misses. Communicating with the client is necessary, but identifying systemic factors is a priority because of the implications for future clients. Focusing on the nurses who were directly involved demonstrates a narrow and short term perspective of safety, which may be perceived as punitive.
The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial? appropriate storage of combustable cleaning solutions principles of body alignment the use of protective clothing the use of ear plugs
principles of body alignment Explanation: The clerical worker is primarily sedentary. The greatest concern would relate to body alignment and positioning. Ear plugs would be most appropriate for the factory worker. The use of protective clothing and the storage of hazardous materials would be topics best suited for janitorial workers.
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? "Never keep firearms in the home with young children." "Always provide close supervision for young children when they are in or around pools and bathtubs." "Store medications in a locked area to prevent children from getting into them." "Never smoke in the bed in the house when young children are present."
"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.
The nurse is caring for a client with Alzheimer's disease. A family member states, "I am afraid I will go to bed one night, and the next morning my loved one will be missing from wandering off." What is the appropriate nursing response? "Clients with Alzheimer's disease often wander." "Adjust sleeping schedules so that you can monitor your loved one as they sleep." "I know, my parent has Alzheimer's disease and I worry about that too." "Consider the Alzheimer's Association 'Safe Return' program."
"Consider the Alzheimer's Association 'Safe Return' program." Explanation: The appropriate nursing response is to refer the client's family member to a program such as the Alzheimer's Association's "Safe Return" program. This validates the family member's concern and provides a resource. Validating that clients with this disorder wander does not provide a solution to the concern, and recommending that the family member adjust sleeping schedules is not realistic. The nurse should not verbalize his or her own concerns, but rather should focus on the needs of the client and family members.
A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? "How have other organizations responded to nurses in events like this?" "How did the nurse's actions contribute to this error?" "Have the client and the family been informed about this?" "What is the organization's legal liability in this matter?"
"How did the nurse's actions contribute to this error?" Explanation: Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability and communication with the client are valid considerations, but none directly promote the establishment of a just culture. It is of little value to learn how other organziations have responded to nurses during similar events once the research phase of establishing a just culture is completed.
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? "I will sound the alarm before I start moving a patient from a room." "I will leave all doors open after rescuing patients." "I know that nurses are the only ones who can extinguish a fire." "I will rescue clients from harm before doing anything else."
"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 poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? "Is your child breathing at this time?" "Did you leave the household chemical in reach of your child?" "You should not have left your child alone while you showered." "Induce vomiting and call 911 right away."
"Is your child breathing at this time?" Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.
The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? "Let's admit your child to an acute care facility so that we can run more tests." "These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." "This is typical adolescent behavior. Ignore it and it will improve."
"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." Explanation: Some signs of substance use in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.
Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant? "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes." "We place our baby in a front-facing car seat in the middle of the back seat of the car." "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry." "We place our baby in a rear-facing car seat in the back seat of the car."
"We place our baby in a rear-facing car seat in the back seat of the car." Explanation: Children from birth to 2 years of age should remain in a rear-facing infant seat in the back seat of the car until they reach the maximum height and weight for a front-facing child car seat.
Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? Fifth First Eighth Tenth
Fifth Explanation: Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: Heart disease, cancer, and chronic lower respiratory diseases.
A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. Fires are responsible for most hospital incidents. Some people are more at risk for accidents than others. Between 15% and 25% of falls result in fractures or soft tissue injury. A nurse whose behavior is reasonable and prudent, and similar to what would be expected of another nurse in a similar circumstance, is still likely to be found liable if a client falls, especially if an injury results. A person with a history of falls is likely to fall again. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.
A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. Explanation: A history of falls puts the person at risk for falls in the future. Some people are more careless with behaviors, which makes them more prone to injury. Diuretics increase the risk for falls because the client may stand quicker or get up during the night to urinate. Analgesics may cause the client to have an unsteady gait due to drowsiness. Falls are responsible for most hospital incidents, not fires. Approximately 33% of falls result in fracture or soft tissue injury. Responsible and prudent behavior of the nurse will decrease the risk of client injury.
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? Alert the local fire department. Answer all telephone calls and call bells. Activate the fire alarm and notify the appropriate person. Attempt to extinguish the fire.
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 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 Revamping the licensing requirements for foreign-educated nurses Establishment of clinical career ladders Quality improvement (QI)
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.
A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? Advise the client to avoid blinking until after the eyes are irrigated. Flush the eyes with a cool saline solution for a 10-minute period. Wash the eyes with a hypertonic solution for at least 30 minutes. Flush the eyes with water for 10 minutes.
Flush the eyes with water for 10 minutes. Explanation: If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Assure bed alarms are activated Ask visiting family member to stay Conceal IV tubing with gauze wrap Request a sedative from health care provider
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.
Which item would alert the home care nurse to a safety hazard threatening a young child? Padded child safety seat A gated stairway Three blankets in a crib Dangling blind cords
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.
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? Use a quick-release knot to tie the restraint to the side rail. Apply restraints to the hands or wrists, never to the ankles. Ensure that two fingers can be inserted between the restraint and the client's extremity. Remove the restraint at least every 4 hours, or according to facility policy.
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.
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. Put up all four side rails on the bed. Contact the physician for a restraint order. Administer the client's sedative as ordered.
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 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? Use an extension cord to provide freedom of movement. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet. Obtain a three-prong grounded plug adapter.
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.
The nursing assistant has bathed the client who is in restraints. Upon assessing the client on hourly rounds, the nurse determines the client's restraints pose a risk for injury to the client. What assessments would lead the nurse to reapply the restraints? Select all that apply. The client's extremities are in normal anatomic positions. A quick-release knot is used to secure the restraint. The restraint is tied out of the client's reach. The restraint is tied to the side rail of the bed. One finger can be inserted between the restraint and the client's extremity.
One finger can be inserted between the restraint and the client's extremity. The restraint is tied to the side rail of the bed. Explanation: To avoid injury, the nurse would correct the distance between the restraint and the client's extremity. One finger is not enough space. The nurse should be able to insert two fingers in order to prevent neurovascular damage to that extremity. The nurse would correct the restraint being tied to the side rail of the bed. Injury could occur when the side rail is lowered. The restraint should be tied to the frame of the bed. No correction is required for proper application of the restraints, including the client's extremities being in normal anatomic positions, a quick-release knot being used, and the restraint being out of the client's reach.
The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action? Obtain the fire extinguisher. Remove the client from the room. Close the client's door. Activate the fire alarm.
Remove the client from the room. Explanation: In case of a fire, the nurse should (in this order) rescue anyone in immediate danger, activate the fire code system, notify the appropriate person, and confine the fire by closing doors and windows. Therefore, in this instance, the nurse's first action should be to remove the client from the room.
A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Activate the fire alarm on the unit. Evacuate clients and staff. Attempt to extinguish the fire. Rescue anyone who is in immediate danger.
Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.
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? Keep all pots and pans in lower cabinets. Lock all cabinets that contain cleaning supplies. Restrain the baby in a car seat. Give warm bottles of formula to the baby.
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 nursing supervisor is concerned about excessive use of physical restraints on the unit. What interventions would the nursing supervisor employ to decrease the use of restraints? Select all that apply. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. Review and change, if needed, current policies at the agency for adherence to accepted national standards. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Encourage the nurses to use medications instead of physical restraints. Obtain additional bed alarms or position-sensitive electronic devices for use as needed.
Review and change, if needed, current policies at the agency for adherence to accepted national standards. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints. Evaluate each client who is restrained and consult with the client's nurse about the use of the restraint. Obtain additional bed alarms or position-sensitive electronic devices for use as needed. Explanation: The nursing supervisor who is trying to decrease the use of physical restraints has several interventions that can be employed. Current policies at the agency should be reviewed for adherence to accepted national standards. Policies should be changed, if needed. Classes should be provided for the nursing staff about proper use of restraints, alternatives to restraints, and documentation requirements. The nursing supervisor can evaluate each client in restraints for appropriate use and discuss the use of the restraints with the client's nurses. Alternatives to restraints are using bed alarms and/or position-sensitive electronic devices for clients who may attempt to get out of bed without assistance. Medications that are used to keep the client in bed are considered chemical restraints and not appropriate for use as such.
The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? Impaired Bed Mobility Related to Muscle Wasting Chronic Confusion Related to Long-Standing Alcohol Use Noncompliance Related to Medication Regimen Risk for Injury Related to Agitation
Risk for Injury Related to Agitation Explanation: The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.
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. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control. Sedate her with sleeping pills and leave the restraints on.
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.
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. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. The nurse calls the primary health care provider to fill out and sign the safety event report. The nurse adds the information in the safety event report to the client health record.
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.
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 notify the primary care physician about the bruises. The nurse should request permission from the client to photograph the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises.
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.
A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. The report provides a detailed and objective account of the circumstances before, during, and after the event. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed.
The report provides a detailed and objective account of the circumstances before, during, and after the event. Explanation: Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports.
A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? Respond to the past history of the client (including previous falls) to determine the need for restraints. Individualize the use of restraints and choose the most easily used device. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.
Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. Explanation: The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.
A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply. Keep identifying information posted on the web sites. Use filtering software to block objectionable information. Emphasize that everything read online is usually true. Be alert for downloaded files with suffixes that indicate images or pictures. Investigate any public chat rooms used by the children.
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 (USAA Educational Foundation, 2009).
The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group? Use protective sporting equipment. Be cautious of electrical outlets. Do not text while driving. Use caution when descending stairs.
Use protective sporting equipment. Explanation: School-age children in the 7th grade are physically active, which makes them prone to play-related injuries. Therefore, protective sporting equipment should be used. Information about not texting while driving is more appropriate for teenagers and adults who drive. Using caution around electrical outlets and stairs is more appropriate for parents of toddlers.
The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include? Snap the gloves when applying them to ensure proper fit. Use powdered gloves. Wash hands thoroughly after removing gloves with a pH-balanced soap. Use hand cream or lotion after removing gloves to preserve skin integrity.
Wash hands thoroughly after removing gloves with a pH-balanced soap. Explanation: If latex gloves are used, nurses should wash hands thoroughly after removing gloves with a pH-balanced soap. They should use powder-free, not powdered, gloves. They should not snap gloves when applying them. They should avoid using oil-based hand creams or lotions.
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 asking the unlicensed assistive personnel (UAP) to sit with the client application of devices that reduce the client's ability to move arms articulating the reason for use of a physical restrictive device to the client's spouse
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 recognizes that assessment for sensory-perceptual alterations is a priority for which client? an 84-year-old male with four recent driving violations a 12-year-old male who sprained his wrist skateboarding a 42-year-old female who is a single mom with a sick child home from school a 16-year-old pregnant female who has morning sickness
an 84-year-old male with four recent driving violations Explanation: An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration.
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: falls from staircases. falls from beds. play-related injuries. automobile accidents.
automobile accidents. Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.
A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: document strategies in the client's health record for preventing future incidents. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. fill out an incident report, with the goal of preventing a similar event in the future. complete an incident report to determine who was primarily responsible for the event.
fill out an incident report, with the goal of preventing a similar event in the future. Explanation: Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessarry behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report.
The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention? electrical outlets with covers over them one fire extinguisher noted in the kitchen hot water heater thermostat set at 130 degrees F (54.4 degrees C) infant's sleepwear is made from flame-resistant fabrics
hot water heater thermostat set at 130 degrees F (54.4 degrees C) Explanation: The nurse will intervene if the hot water heater thermostat is set above 120 degrees F (48.8 degrees C). This could cause burning to an infant's skin. Other findings enhance safety within the home.
During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: mass trauma terrorism. bioterrorism. nuclear terrorism. chemical terrorism.
mass trauma terrorism. Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.
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? has client sit in bed for a few moments before standing places bed at lowest setting clears a path from bed to bathroom provides slippers for ambulation
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.
