Chapter 27: Safety, Security, and Emergency Preparedness

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 take risks. Explanation: Adolescents tend to be impulsive and take risks as a result of peer pressure, so this is important for the nurse to teach the adolescent. Buying protective sporting equipment, placing household cleaners out of reach, and supervising the child on the changing table are not age-appropriate teachings to include.

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 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.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink. Explanation: Electrical shock can result if appliances such as a hair dryer come in contact with water. The hair dryer should be removed away from the sink. Other findings reflect appropriate safety measures.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs." Explanation: The leading cause of injury and death in children 1 to 4 years of age is drowning. Therefore, providing close supervision when children are in or around tubs and pools will help decrease and/or prevent this injury.

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?" 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.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house Explanation: To prevent accidental injury and death in toddlers and preschoolers, parents need to childproof the home environment. Play areas should allow for exploration but still provide for safety. Safety equipment for sports should be taught to school-age and older children. Drug and alcohol education is also typical for school-age and older children. Back to sleep guidelines are relevant for neonates unable to roll independently.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI) Explanation: The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.

A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety?

"I am concerned that the small rugs in your home can be a tripping hazard." Explanation: The nurse can open up the conversation by stating concern about the small rugs. The conversation provides education through problem-solving. If the nurse demands or states generalities, the nurse will not gain the needed cooperation from the client. The older adult client should remove all area rugs, even if skid resistant, to prevent accidental injury.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else." Explanation: The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first.

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to help prevent motor vehicle accidents? Select all that apply.

Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit. Explanation: Safe driving behaviors that help limit occurrences of motor vehicle accidents include reducing the number of other adolescents in the car, never texting while driving, and obeying the speed limit. Driving at night should be limited, not encouraged. Although wearing a seat belt should be performed, this action does not prevent accidents rather it help keep the drive and passengers safe if an accident occurs.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

Obtain order from a licensed provider within minutes of restraint application. Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting. Explanation: An order for restraints from the licensed health care provider must be obtained within minutes after the restraint is applied. Frequent and regular nursing assessments are required of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing the restraint. The nurse must explain the need for restraints with the family. When the assessment findings indicate that the client has improved, restraints must be removed.

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?

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 teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table. Explanation: Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Therefore, the nurse teaches the caregiver to supervise the child on the changing table. Placing household cleaners out of reach, buying protective sporting equipment, and teaching about peer pressure risks are appropriate for older children, not infants

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints Explanation: Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

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 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.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

administering medications to the client Explanation: A large proportion of adverse events in hospital settings involves medication administration. It is generally accepted that medication administration is more risky than communication of testing results, client transfers, or client admissions.

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

"Check breathing and heart rate." Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply

Drowsiness Headache Vomiting Explanation: Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?"

"Only certain members of the health care team can extinguish a fire." Explanation: All members of the health care team are educated about how to extinguish a fire. Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction. The other statements are appropriate.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear." Explanation: All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child who weighs 31 lb (14 kg)?

"We place our child in a front-facing car seat in the back seat of the car." Explanation: Infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for 2 years or more with weight limits averaging 35 to 40 lb (15.5 to 18 kg).

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week Explanation: Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and be a factor in adverse events. The remaining three scenarios are within the normal realm of practice. A nurse transferring to another unit is able to provide care to clients within the scope of practice; this does not present a hazardous situation. Placing three side rails up assists with prevention of falls and is not classified as a restraint. Administering medications to four clients is an acceptable number of patients to be assigned to administer medications for most clinical settings.

The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include?

Be alert for signs of peer pressure. Explanation: Adolescents tend to be impulsive and take risks as a result of peer pressure. Deep bodies of water and household cleaners pose risks to toddlers who do not yet understand danger. Climbing can place infants and toddlers in danger.

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength Explanation: Falls are a significant health hazard for the older adult. Regular exercise has a positive effect on bone and muscle strength, balance, and flexibility of joints. A high-fiber, low-fat diet may be advisable for many older adults, but it is not specific to promoting client safety in the home. Information about promoting regular sleep may improve safety for select groups of clients, but will not have the specific benefits for fall prevention achieved by improved balance and muscle strength. Avoiding liquids before bedtime may decrease the need for night time trips to the bathroom, and may be a valid recommendation for some parties. However, the outcome benefits are not as specific to fall prevention in health older adults as exercise, balance, and muscle strength.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

Establish the nurse's role during a disaster Explanation: During a disaster nurses will have multiple roles. In addition to their clinical knowledge, they may be responsible for triage, counseling and various other duties. Fear, panic, anger, and exaggerated concerns are expected. Disaster preparedness is imperative, as well as knowledge of resources. Communication with leadership should be established and sources for reliable information monitored. However, none of the necessary actions can be performed if the nurse lacks clarity on his or her role.

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?

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.

The surgical nurse is preparing a client for surgery on the left leg. Which nursing action(s) are appropriate? Select all that apply.

Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedural verification protocol. Call for a "time-out" immediately before surgery begins. Explanation: To prevent wrong site, wrong procedure, and wrong person surgery, the nurse will mark the left leg as the one intended for surgery, have the client mark the body part intended for surgery, conduct a preprocedural verification protocol, and perform a "time-out" immediately before surgery to double-check all the surgical information regarding the client and required documents. It is not within the nurse's scope of practice to explain the surgical procedure to the client. The client will have been provided with a detailed education about the procedure in the preoperative assessment. The client will not have been able to provide informed consent to the procedure without a detailed description provided by the surgeon.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns. Explanation: Most people who die in house fires die of smoke inhalation rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and the members of other health disciplines. Explanation: Teamwork and collaboration is one of the core QSEN competencies, and is exemplified by increasing communication between different disciplines. The six QSEN competencies do not explicitly address financial costs of care, higher levels of education for nurses, or increased partnership between hospitals and educational institutions.

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for Poisoning related to medications in unlocked cabinets Explanation: Because this child lives with his grandmother, who has a diagnosis that requires multiple medications, and because the family cannot purchase safety devices to safety-proof the house, this child is most at risk for poisoning related to medications in unlocked cabinets. There is no evidence that there is peeling paint in the home, or substance use, or that the child is being left unattended.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures. Explanation: Parents should keep identifying information private (e.g., full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything read online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (e.g., .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom (USAA Educational Foundation, 2009).

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords Explanation: As babies gain neurologic and musculoskeletal functions, they learn and explore by pulling objects to themselves and placing almost everything in their mouths. Cords, tablecloths, plastic bags, bottles, and cans are tempting, dangerous objects that caregivers must strive to keep out of reach

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her?

"At the age of 6 your child should be using a booster seat." Explanation: When children outgrow standard car seats, parents and caregivers should use booster seats, preferably those that use combination shoulder and lap belts, until the car seat belt fits appropriately (typically when they have reached 4 ft, 9 in [1.43 m] in height and are between 8 and 12 years of age).

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order." Explanation: A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter. Explanation: Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter. Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client?

Skeletal muscle paralysis that progresses symmetrically and in a descending manner Explanation: Exposure to botulism results in skeletal muscle paralysis that progresses symmetrically and in a descending manner. Muscle weakness often occurs, which can abruptly result in respiratory failure. One of the common symptoms of smallpox infection is flu-like symptoms. Skin lesions with local edema that worsens is associated with anthrax. Petechial hemorrhages result from viral hemorrhagic fevers.

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 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.

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Use of blankets, pillows, and stuffed animals in the crib Explanation: Infant safety education should include use of approved car seats and not booster seats. Booster seats are used for the pre-school child with recommended height and weight. The use of skid-proof mats in the bathtub are topics more suited to the parents of preschool children. Infants are not likely to be physically able to access guns in the home. Infants should not have pillows, stuffed animals, or blankets in the bed due to the risk of suffocation.

A group of children is preparing for a camping trip in the woods with camp counselors. The children are learning about health promotion activities to use on their upcoming camping trip. Which principle is most important for the nurse to teach to promote a safe camping experience?

Using the buddy system during the trip Explanation: The buddy system, a prearranged agreement between two or more people to provide mutual companionship and to monitor each other's whereabouts and well-being during certain high-risk activities, is an important outdoor and water safety strategy and the most important principle for the nurse to teach to ensure a safe camping experience. Wearing sturdy shoes for hiking, avoiding poison ivy and running on smooth surfaces are strategies to stay safe, but the buddy system is the most important to ensuring an overall safe camping experience.

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which condition increases the client's risk for falls? Select all that apply.

climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning Explanation: Unintentional injuries at home are common for the older adult. Safety habits, no longer reinforced by watchful adults, can become rusty; disregard of judgment, overconfidence, or ignorance can place adults in danger's path. In addition, adults may consume alcohol, which interferes with judgment to interpret the environment and with physical capabilities to operate machinery, thus contributing to injuries.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states

"I should be able to fit two fingers between my chin and the chin strap." Explanation: The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath the chin. The chin strap needs to be snug, and the ability to fit two fingers between the strap and the chin indicates it is not snug enough. The helmet should rest 1 in (2.5 cm) above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger.

Which statement should the nurse include in the teaching plan for a family learning about fire safety?

"Most people who die in home fires die from inhalation and not from burns." Explanation: Most people who die in home fires die from inhalation and not from burns. Cigarette smoking is a common cause of house fires when people fall asleep in a chair or bed while smoking. Electric heaters can also be a risk for fires in the home, and most fires occur inside the home.

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics Explanation: Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.

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.

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 nurse is evaluating risk factors for a developmentally diverse group of clients. Which client(s) is at risk for safety? Select all that apply.

A toddler allowed to crawl in a house that has not been childproofed An older adult client with a shuffling gait Explanation: Each developmental level carries its own particular risks. Health care needs and safety risks change as individuals progress from infancy to the older adult stage. Two clients at risk for safety concerns are the toddler crawling in a house that is not childproofed and the older adult with a shuffling gait. The machinist has a lifestyle risk factor, the executive has a psychosocial risk factor, and the 42-year-old client who suffered a stroke has mobility risk factor.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate. Explanation: Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation. Explanation: The diverse physiologic and psychologic capabilities of people and encounters with various safety hazards across the lifespan put various age groups at risk for different safety concerns and potential injuries. Older adult clients are at a higher risk for falling. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors. Explanation: For older adult clients with cognitive impairment, such as when clients are diagnosed with dementia or Alzheimer disease, the tendency to wander can pose a serious risk to the client's safety. In the nurse's plan of care for this client, it is necessary to ensure the client's environment is assessed for and adapted to prevent the client from exiting the care facility unaccompanied. The nurse will place STOP signs on all exit doors to communicate to the client that the client should not open exit doors. The nurse can ensure there is a bell over the client's room door so there is an audible signal to care providers when the client is out of the room. Physical restraint is an intervention that is used sparingly with clients with cognitive impairment because it is invasive and traumatizing. The application of physical restraint is reserved for situations in which the client is placing one's own safety in danger. An intervention such as this would not be used periodically throughout the day. The nurse will implement nonviolent crisis intervention such as therapeutic communication, redirection and occasionally chemical restraints if the client is sufficiently agitated to place oneself or others at risk. Security personnel can be perceived as threatening by the client, and their presence could lead to further agitation and long-term harm to the client. The presence of security is required only on a case-by-case basis. The client should only take a walk outdoors if accompanied by a care provider or family member.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint Explanation: The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies. Explanation: The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm. Explanation: To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action?

Notify the primary care provider and obtain an order for a client sitter. Explanation: The nurse's best next action is to call the primary care provider for a client sitter, an alternative way to provide around-the-clock safety. Alternatives to restraints should be explored first. The client has a postoperative abdominal incision, which is a contraindication for the application of a waist restraint because it would increase intra-abdominal pressure and place strain on the wound. The primary care provider did not order wrist restraints, so the nurse would have to get an order for them, if they were needed. Wrist restraints are applied when a client may try to pull out an intravenous line and harm self from such action. It is not used to help keep the client in bed. The family is out of state and may not be able to come and watch the client around the clock or arrive in a timely manner to be able to help.

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action?

Offer the client bathroom privileges and assistance Explanation: Restraints for patients 18 years and older must be removed every four hours, six hours is too long. Choosing the least restrictive restraint will help to prevent injury and skin breakdown on bony prominences. Keeping arm restraints loose can potentially harm the client. Paper tape is insufficient to secure restraints. The nurse must attend to the client's basic needs regardless of whether he or she is restrained.

An individual calls the telehealth nurse and reports that a family member was just found on the floor of an enclosed garage while a car was still running. The family member is unconscious and cherry red in color. What direction will the telehealth nurse provide?

Open garage doors and windows, and call 911. Explanation: Carbon monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache, and inability to move as carbon monoxide poisoning. The telehealth nurse will tell the caller to open doors and windows to ventilate the garage, and to call 911. Other actions are inappropriate.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide a bedside commode and ensure adequate lighting. Explanation: The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered a justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever. Explanation: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety Explanation: Added stimulation can increase the maladaptive behaviors of the client; therefore, the nurse should first reduce the distressing environmental stimuli. Proper communication of client status change is a legal requirement of nurses, and documentation provides a means of communication between interdisciplinary teams and provides continuing of care. However, notifying the health care provider and documenting the change in status are not the priority action. Restraints are to be used as a last resort in client care.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to the Joint Commission and to relevant state agencies Explanation: At issue here is that the nurse directly exposed a client via direct bloodline to a client infected with HCV. The uninfected client could become infected and require lengthy treatment. Sentinel events must be reported to the Joint Commission and to relevant state agencies. Sentinel events are not normally publicized, and incident reports are not provided to the ANA. Matters related to financial compensation would likely involve the courts, not the Joint Commission or health agencies.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying. Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure Explanation: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

The nurse is educating parents of toddlers on how to prevent injuries and promote safety for their children. What are age-appropriate safety interventions for this age group? Select all that apply.

Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Do not leave the child alone in the bathtub or near water. Explanation: Measures to prevent injuries and promote safety of toddlers include having the poison control center phone number in readily accessible location; using an appropriate car seat for the toddler; supervising the child closely to prevent injury; childproofing the house to ensure that poisonous products, drugs, and small objects are out of toddler's reach; never leaving the child alone and unsupervised outside; and keeping all hot items on the stove out of the child's reach. Proper safety equipment for bicycles and scooters, and practicing emergency evacuation measures, are appropriate education measures for the preschooler. Providing drug, alcohol, and sexuality information is appropriate for the school-age child.

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply.

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy Explanation: The acronym DAME (Drug/alcohol use, Age-related physiologic status, Medical problems, Environmental) assists the nurse to asses fall risk at home. The diuretic furosemide may cause the client to fall during frequent and possibly urgent trips to the toilet. Furosemide may also cause volume depletion and dizziness in standing. Diabetic neuropathy contributes to falls because of loss of normal sensation in feet and lower extremities. Consuming alcohol contributes to loss of balance, volume depletion and urinary urgency. Living on one floor and performing regular exercise describe positive characteristics for fall prevention.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color. Explanation: The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

The importance of consistent seat belt use Explanation: Seat belt use is an important safety precaution to teach audiences of all ages. Improper seat belt use (or lack of seat belt use) increases the risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident. Explanation: An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises. Explanation: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

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?

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.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior Explanation: Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement. These are generally used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, staff, or others. Physical restraints are devices that immobilize or reduce the ability of a client to freely move his or her arms, legs, body, or head. Asking the UAP to sit with the client is a diversion method. Articulation of rationale for using a physical restraint is part of nursing teaching.

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:

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:

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 necessary 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.

When educating families on fire safety, it is important to:

have a meeting place outside the home. Explanation: The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.

A 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?

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.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers Explanation: Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors. Cleaning supplies and lead are more significant sources of poisoning in infants and children. Alternative and complementary therapies carry risks, but it would be unnecessary to recommend complete avoidance of all such therapies.

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. 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?

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.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom Explanation: Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is an unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children.