Fund Ch. 27 PrepU

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.

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."

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."

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

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.

"At the age of 6 your child should be using a booster seat."

*safety with stairs *water safety *electric outlet safety *childproof latches

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

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?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

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.

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick.

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

keeping medications in clearly labeled containers

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.

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."

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."

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 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."

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply.

*Infants should be rear-facing up to the age of 2 years. *Booster seats should be used until the child is 4 ft 9 in (145 cm) tall.

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.

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 would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

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.

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?

Centers for Disease Control and Prevention

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

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?

Ask to examine the client alone in order to speak to her privately.

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.

A school-age child is admitted to the emergency room with a possible 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

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

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

Dangling blind cords

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.

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 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.

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.

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.

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

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.

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?

Reduce the temperature on the water heater.

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.

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?"

The client will demonstrate safety measures to prevent falls.

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.

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

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 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

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.

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

nurse practitioner

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