Fundamentals of Nursing CH 19: Safety

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

Dangling blind cords

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

Dilute with water or milk.

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 79-year-old client with a history of osteoporosis experienced a fall while attempting to walk independently to the hospital washroom to urinate. How can the nurse best prevent a repeat of this incident?

Encourage the client to ring the call bell when the client has the urge to void.

The nurse is preparing to give an educational program to parents of toddlers related to promotion of safety. What should the nurse discuss with parents to reduce the risk of injury for this developmental stage? Select all that apply.

Falls from stairs Accidental drowning Electrocution from outlets

An older adult woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury?

Fractured hip

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.

A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices?

Helmet

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

Household cleaners must be kept out of reach.

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

Implement drowning-prevention strategies.

When educating parents of preschoolers, what is most important for the nurse to include in the presentation?

Keep chemicals in a locked cabinet.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

A nurse is caring for an a client with asthma who has developed severe allergic reactions to latex. Which measure should the nurse take to protect a latex-sensitized client?

Keep the client's unit free from latex products

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.

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

Nurse practitioner

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 door and windows, and call 9-1-1.

A nurse is assigned to care for a 10 month-old boy. Which activity should be the priority for the nurse?

Protect the toddler from injury.

A fire has erupted in the trash can on the unit and the nurse implements the protocol for fire safety for the facility. Another nurse obtains the fire extinguisher and is preparing to use it. What would the nurse do first?

Pull the pin.

An older adult client is planning to move with her son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep his mother safe. What would the nurse most likely include?

Put a small nightlight in the hall and stair.

The acronym health care workers use to remember the safety procedures in the event of fire is:

RACE (rescue; alarm; confine; evacuate).

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 has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

Repeat or read back the order.

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 healthcare items with latex-free equipment.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of medication. Which measure would be most effective at protecting a toddler from accidental poisoning with medication?

Request childproof caps on all prescription medications.

A nurse is caring for a restrained client who has suicidal tendencies. Which of nursing diagnosis is most appropriate for this client?

Risk for Injury

What generalization can be made about safety in client care?

Safety is a paramount concern underlying all nursing care.

A group of nursing students is reviewing information about restraints. The students demonstrate understanding of the information when they identify which of the following as a chemical restraint

Sedative

A group of nursing students is reviewing information about restraints. The students demonstrate understanding of the information when they identify which of the following as a chemical restraint?

Sedative

The nurse is assessing the client's sensory input. Which assessments should be included? Select all that apply

Sensitivity to touch Sensitivity of sharp to dull stimulation Ability to maintain balance

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

Social pressure

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.

A male client with early-stage Alzheimer disease is being discharged home after a hospital admission and his wife will be his sole caregiver. What action should the nurse encourage the wife to take in order to reduce her husband's risk of experiencing a fall in the home?

Teach the wife to remove loose rugs from the floors in the home.

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.

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure ulcer on his 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 ulcer.

Which action directly addresses one of the Joint Commission 2015 Hospital National Safety Goals?

A hospital has set ambitious targets for reducing the incidence of catheter-related urinary tract infections.

A nurse is caring for an 18 month-old boy status post a tracheostomy. He is recovering well and wanting to be more active. The nurse selects a toy from the playroom for him to play with. Which toy is most developmentally appropriate?

A rocking horse

An 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 parent visits the pediatrician's office and complains to the nurse practitioner about her teenager who sleeps too much. It would be appropriate to instruct this parent that

Adolescents need more sleep for growth

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client.

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse?

Ask the client "what if" questions to determine level of thought organization

The client tells the nurse that he needs to use the restroom. Which safety intervention must be done by the nurse first?

Assess the need for assistance with ambulation.

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.

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.

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

Be alert for signs of peer pressure

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

Be alert for signs of peer pressure.

A nurse is providing a safety program on childhood poisoning for a group of parents of young and school-age children. The nurse determines that the education was successful when the group states:

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

The nurse is teaching the caregiver of a school-age child about safety. Which teaching will the nurse include?

Buy protective sporting equipment.

The nurse is caring for a client with a latex allergy. When the dietary tray arrives, the nurse notes that it contains a hamburger with lettuce and tomato, baked potato, apple, chocolate chip cookie, and small serving of milk. What is the appropriate nursing action?

Call Nutrition Services for a plain hamburger.

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

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

Contact healthcare provider to clarify order.

When administering an injection to a client with hepatitis C in a health care facility, the nurse sustained a needlestick injury. Which ensuing action would be most important?

The nurse needs to file an incident report after the event occurs.

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's 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.

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?

The students will demonstrate proper use of safety equipment while playing sports.

The goal of evidence-based practice related to restraints is to avoid the use of restraints.

True

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 most appropriate for this age group?

Use protective sporting equipment

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH balanced soap.

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

administration of an antipsychotic agent to alter the client's behavior

In large metropolitan areas, clients who suffer from asthma will be affected by:

air pollution

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety? (Select all that apply.)

area rugs kept on the stairs without carpet dimly lit hallways waxed floors

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

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

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

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 nurse instructs the family of an older adult client with a visual impairment and decreased mobility that the most common problem for these clients is related to:

falls

What is the leading cause of injury-related deaths in adults 65 and older?

falls

A nurse has been appointed to oversee safety measures in an assisted living facility that caters to older adults. The nurse should prioritize measures aimed at reducing residents' risks of:

falls.

A client went missing from a long-term care facility and an emergency code was called. After a search of one 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.

The nurse is preparing to administer medication to a client. Which validation of client information is appropriate?

full name and date of birth

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

gas stove

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

have a meeting place outside the home.

The nurses on a critical care unit can utilize the safety strategy of redundancy by:

having two nurses independently check the dosage of high-risk medications.

The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention?

hot water heater thermostat set at 130 degrees F (54.4 degrees C)

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 nurse is providing care for a client whose blood pressure has been gradually dropping over the course of a shift. The nurse has decided to inform the client's primary care provider by telephone using the SBAR tool. The nurse will end this communication by:

making a suggestion about what she believes to be the best actio

The surgical nurse is preparing a client for surgery on the left leg. The client is awake, alert, and oriented. Who does the nurse identify that should mark the leg that will undergo the surgical procedure? (Select all that apply.)

nurse surgeon client

Which agent has the potential to affect the integrity of latex gloves?

oil-based lotions

A nurse is preparing a community lecture about safety considerations for various age groups. For which age group would the nurse especially emphasize the prevention of falls?

older adults

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 occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial?

principles of body alignment

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 not comply with a least restraint policy?

raising all side rails while the client is in bed

An 18-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

sports-related activities.

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

A group of girls is camping in the woods with camp counselors. They should be instructed to:

use the buddy system

The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed?

1 medium Banana

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

19-year-old male college student majoring in physics

The nurse is caring for four clients. Which client does the nurse anticipate is at highest risk for latex sensitivity?

27-year old who cannot eat avocados

A nurse is administering the Hendrich Fall Risk Tool to a client. What is the cutoff Final Risk Score for the client to not be considered at risk for falling? Record your answer using a whole number.

5

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 bath water before stepping in."

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

"Clear the clutter from the stairways and walkways."

The nurse is caring for a client with dementia who lives alone at home and has begun wandering. What is the appropriate nursing response when the caregiver states, "What can I do? I am afraid my spouse is going to get lost."

"Consider the Alzheimer's Association 'Safe Return' program."

A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error?

"How did the nurse's actions contribute to this error?"

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

"I am going to remove all those throw rugs on the floor."

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?"

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."