Foundations Ch. 27 Safety

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."

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."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

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?

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

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.

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

-Communication ability -Developmental level -Mobility Pg 752

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.

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. Pg. 778

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

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 full name and date of birth

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.

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

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

Obtain a three-prong grounded plug adapter.

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

Offer the client bathroom privileges and assistance

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. Pg 772

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

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.

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?

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?

Rescue anyone who is in immediate danger. Pg 776

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for Poisoning related to poor eyesight and the inability to read medication labels

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

The client will not experience a fall and remains free of injury. Pg. 757

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. Pg 772

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.

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.

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?

Use night-lights in bedrooms and bathrooms.

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 Pg. 784-786

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

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

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

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

social pressure

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. Pg 774

The unlicensed assistive personnel 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 assessment(s) represents a rationale for removal or adjustment ? Select all that apply.

-One finger can be inserted between the restraint and the client's extremity. -The restraint is tied to the side rail of the bed. Pg 774-775

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply.

-The client's family must be involved in the decision and care plan. -Alternatives to restraints and less restrictive interventions must have been implemented and failed. -The benefit gained from using a restraint must outweigh the known risks for that client. Pg 786-789

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 toddlers

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 alarm lever

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.

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?

rocking horse

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."

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect:

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services