Craven Ch. 23: Safety

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

"Always test the temperature of bathwater before stepping in."

A nurse is providing a safety program on childhood poisoning for a group of parents of preschool and school-age children. The nurse determines that the education was successful when the makes which statement?

"Berries and seeds that children find out in the woods are not safe for them to eat."

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."

There is a fire in the neurology unit of a health care facility. What would be most appropriate to avoid in this situation?

use of elevators

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."

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."

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?"

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."

A new parent asks about the use of a car seat for a newborn. What information would the nurse prioritize when teaching the parent about car safety seat use with newborns?

"You should use a rear-facing safety seat in the back seat for the first year or until your infant weighs more than 20 lb (9 kg)."

A nurse is making a visit to a client's home and, during the assessment, the nurse notices some possible hazards. What would the nurse identify as potential hazards? Select all that apply.

clutter on the stairs nonworking smoke detector electrical outlet with several extension cords evidence of mice droppings

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which topic for staff education is most likely to benefit the greatest number of residents?

educating nurses on how to prevent falls

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies client's full name and date of birth

A nurse working in the intensive care unit begins to realize the potential fire hazards in a hospital setting. When should the nurse demonstrate how to function during an emergency?

in advance of the actual emergency or disaster

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

keeping medications in clearly labeled containers

A mother brings her 2-year-old child to the clinic for a visit. During the interview the mother voices concern about her child's safety. The nurse integrates knowledge of which of the following about a toddler when responding to the mother?

neurologic system is immature

A nurse is attending to an adolescent client at the health care facility who has sprained an ankle during a soccer match. What is the most common reason for an adolescent to risk injury?

peer pressure

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords.

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

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does notcomply with a least restraint policy?

raising all side rails while the client is in bed

A nurse has attended a fire safety training program for the facility. The nurse demonstrates understanding of how to prioritize actions during a fire by doing the actions listed below. Place the actions in the sequence that would best demonstrate the nurse's understanding.

removing the client from immediate danger pulling the alarm and calling "code red" closing all the doors and windows evacuating the clients if directed

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 to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

temporary application of devices that reduce the client's ability to move arms

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

A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?

using carbon monoxide detectors and alarms

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which action by the new nurse would require the charge nurse to intervene?

waiting outside of the closed bathroom door while the client uses the toilet

The nurse is assessing clients for risk factors in the workplace. Which clients would be at risk for injury due to the environment of the workplace? Select all that apply.

worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns nursing assistant who lifts clients in a nursing home

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."

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."

Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home?

"I have removed all throw rugs on the floor."

A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. Which would be most appropriate to include?

"Install handrails in stairways and bathrooms."

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions?

"It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."

A nurse has applied restraints to a client as ordered at 9 p.m. The nurse adheres to the guidelines for restraint use by removing them at which time?

11 p.m.

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

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.

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?

Activate the fire alarm and notify the appropriate person.

A nurse is caring for a restrained client who has suicidal tendencies. How should the nurse intervene to decrease the risk of injury?

Assess for circulation, movement and sensation

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?

Call for assistance to remove the client from the area.

A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse?

Get the victim out of the present environment.

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns?

Keep hot substances away from the baby.

A nurse is preparing to provide care to a client who is receiving radiation therapy for cancer; the radiation source will be kept in the client's room. Which action would be most important for the nurse to do?

Limit own exposure to radiation to the minimum time.

Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls?

Lock wheels on beds and wheelchairs.

Use of which restraint requires the nurse to stay with the client until the restraint is discontinued?

Mummy restraint

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.

The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include?

Place all household cleaners out of reach.

Mr. Ames, age 84, has just been admitted to the hospital for the treatment of pneumonia. In addition to this diagnosis, Mr. Ames also has stage II Alzheimer's disease and is disoriented to place and time. As the night has progressed, he has become increasingly agitated, pulling out his intravenous catheter and wandering throughout the unit. He has become more agitated as the nurses have attempted to reorient and redirect him. Which intervention should the nurses perform?

Position Mr. Ames' bed closer to the nurses' station and perform an assessment.

A nurse is assigned to care for a hospitalized toddler. Which activity should be the highest priority for the nurse?

Protect the toddler from injury.

The emergency room triage nurse is assessing a client who may have been exposed to small pox. Which action would the nurse prioritize in the care of this client?

Quarantining the client and initiating isolation procedures

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?

Rescue anyone who is in immediate danger.

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?

Restrain the baby in a car seat.

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

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

Supervise your child on the changing table.

A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?

Take a physician's order for restraining.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation.

The school nurse is educating 7th grade children about safety. Which recommendation is mostappropriate for this age group?

Use protective sporting equipment.

A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use?

alarm-activating bracelet

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a bonfire, what will the nurse identify?

class A

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?

assisting the client to put on slippers prior to ambulation

A nurse is preparing to administer a chemical restraint to a client. Which information does the nurse need to know prior to administering a medication that can be a chemical restraint?

Other prescribed medications

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.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

class C.

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

Pull the fire alarm lever.

A fire has erupted in a trash can on the unit. The nurse obtains the fire extinguisher and is preparing to use it. Arrange the sequence of steps that the nurse should follow. Use all options.

Pull the pin. Aim the nozzle. Squeeze the handle. Sweep back and forth.

A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire?

Class C

A mass casualty event has occurred in a community. Many health care workers have been employed to assist. A nursing student has volunteered services. With which tasks would the nursing student be asked to assist? Select all that apply.

Take clients' vital signs. Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Hold pressure on a wound that will not stop bleeding.

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.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.

Which age group is most vulnerable to toxic fumes or asphyxiation?

Young children

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 nurse is caring for an 18-month-old client after a tracheostomy. The client is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

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

A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply.

administration of sedation four side rails up having a parent stay with the child

The nurse has been notified that a client who has traveled outside the country is being admitted to the hospital. The client has a diagnosis of dengue fever, a viral hemorrhagic fever. What safety measures would the nurse implement prior to admission of the client to protect the other clients on the floor? Select all that apply.

Assign the client to a private room that has negative-pressure capabilities. Stock the anteroom with gowns, gloves, and N95 respirators. Plan to instruct visitors how to place a surgical mask before entering into the client's room.

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.

A mother is concerned about the safety of her 18-month-old toddler. What would be mostappropriate for the nurse to include in the education plan for this mother and her child?

Avoid leaving the toddler unattended on top of a bed.

Which intervention to prevent client falls in the acute care setting requires collaboration with a client's primary care provider?

Avoid the use of medications that increase the likelihood of falls.

What would be the best restraint to use on an infant during care for a head wound?

Mummy restraint

A nurse is assessing a client who recently had a stroke. Which assessment would the nurse prioritize to promote client safety?

Neuromuscular status

A grade school nurse is addressing parents regarding car safety. What is a recommended safety guideline for this age group?

Booster seats should be used for children until they are 4'9" (1.43 m) tall or at least 8 years of age.

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply.

Check agency policy for the application of restraints and secure a physician's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need.

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

A nurse hears a client call and finds that the client's room has caught fire due to an electrical short circuit. The nurse evacuates the room and raises an alarm. Which of the following types of extinguishers should the nurse use in this situation?

Class C

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply.

Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly.

The nurse is reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action?

Contact the health care provider to clarify the orders.

A nurse uses a restraint when caring for a client with a psychiatric disorder who has become violent. What would be most important for the nurse to keep in mind?

Nurses may use direct supervision and communication to reorient the client.

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.

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall?

Orient the client to the room and environment upon admission.

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is the priority?

Evacuate the client.

Mr. Geno is an 87-year-old client in a nursing home who keeps trying to get out of bed to use the bathroom, despite having a catheter in place. Which intervention would help keep this client safe and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his catheter.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from unintentional poisoning?

Keep cleaning solutions locked up.

The older adult client was admitted to the emergency department for accidentally overdosing on a prescribed medication. The client is prescribed several medications that have varying frequencies for administration. The nurse is providing tips to the client to prevent such an occurrence from happening again. What instructions would the nurse provide to the client? Select all that apply.

Place pills in a pill dispenser that provides for separate dosing throughout the day. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Contact the pharmacist or primary care provider about questions regarding medications. Request large-print medication labels on each of the prescribed medication bottles.

The nurse is caring for a client with dementia. The client has a history of wandering. Which intervention(s) will the nurse implement to reduce the client's risk? Select all that apply.

Record exactly what the client is wearing each morning. Place a large STOP sign on all exit doors. Place an audible bell over the client's room door.

The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply.

Reduce stimulation, noise, and light. Provide a safe environment. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

There is a fire in the trashcan in the client's room. What is the nurse's first priority?

Remove the client from the room.

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?

Replace common health care items with latex-free equipment.

Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for Suffocation

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.

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a gasoline fire, what will the nurse identify?

class B