NUR 105 Chapter 28
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? A) "Always provide close supervision for young children when they are in or around pools and bathtubs." B) "Never smoke in the bed in the house when young children are present." C) "Store medications in a locked area to prevent children from getting into them." D) "Never keep firearms in the home with young children."
A) "Always provide close supervision for young children when they are in or around pools and bathtubs."
The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide? A) Open doors and windows. B) Wait inside until emergency personnel arrive. C) Allow emergency personnel to apply oxygen. D) Recommend that carbon monoxide detectors be installed in the home.
A) Open doors and windows.
A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply. A) The care team meets with the client and family promptly to identify their preferences for treatment. B) The care team ensures the client receives treatment promptly whenever possible C) Nurses proactively identify threats to the client's safety that may occur as treatment is provided. D) Each member of the care team uses the best available technology to organize and provide care. E) Treatments are chosen with the goal of minimizing the financial burden on the health care institution.
A, B, C, D
A pediatric nurse is discussing injury prevention with a group of new parents. What are the leading causes of mortality and morbidity in children? Select all that apply. A) Unintentional gunshot wounds B) Drowning C) Accidental poisoning D) Suffocation E) Complications of medical care
A, B, C, D
A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance? A) Nausea, vomiting, and diarrhea B) Cough, dyspnea, and fatigue C) Abdominal pain and hematemesis D) Ulcerated skin lesions
B) Cough, dyspnea, and fatigue
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? A) Apply restraints to the hands or wrists, never to the ankles. B) Ensure that two fingers can be inserted between the restraint and the client's extremity. C) Use a quick-release knot to tie the restraint to the side rail. D) Remove the restraint at least every 4 hours, or according to facility policy.
B) Ensure that two fingers can be inserted between the restraint and the client's extremity.
An older adult client has developed diabetic neuropathy. What would be the most important safety education intervention for the client and family? A) Obtain a carbon monoxide detector in the home. B) Reduce the temperature on the water heater. C) Keep the environment warmer in winter. D) Increase the amount of ventilation in the house.
B) Reduce the temperature on the water heater.
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) Outlets and switches have cover plates. B) Machines used infrequently are unplugged. C) A hair dryer is placed next to the sink. D) No extension cords are being used.
C) A hair dryer is placed next to the sink.
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 prioritize what action? A) Complete an incident report to determine who was primarily responsible for the event. B) Document strategies in the client's health record for preventing future incidents. C) Fill out an incident report, with the goal of preventing a similar event in the future. D) Hold a facility-wide meeting to identify strategies for making improvements to the safety of residents.
C) Fill out an incident report, with the goal of preventing a similar event in the future.
Which statement should the nurse include in the teaching plan for a family learning about fire safety? A) "Cigarette smoking is no longer a major cause of home fires because most people smoke outside." B) "Electric heaters are safer and do not usually increase the risk of fire in the home." C) "Most fires occur outside of the home when grilling out or camping." D) "Most people who die in home fires die from inhalation and not from burns."
D) "Most people who die in home fires die from inhalation and not from burns."
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? A) The use of skid-proof mats for the bath tub B) Gun safety in the home C) Correct placement of booster seats for the car D) Appropriate positioning in a crib
D) Appropriate positioning in a crib
A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? A) Perform a vision test with Snellen chart B) Arrange an audiology consult to evaluate hearing C) Assess the client for signs and symptoms of osteoporosis D) Arrange for a skilled home care assessment
D) Arrange for a skilled home care assessment
The community health nurse is performing a home visit to a family with a toddler. Which observation should prompt the nurse to perform safety education? A) Three blankets in the child's crib B) Absence of pads on the stairs C) Use of an electric heater in the house D) Dangling blind cords
D) Dangling blind cords
Which level of health care provider may make the decision to apply physical restraints to a client? a) nurse practitioner b) LPN team leader c) RN nurse manager d) senior personal care assistant
a) nurse practitioner
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? a) Placing the client in a bed with a bed alarm b) Providing a bed that is elevated from the floor c) Raising all the side rails of the bed d) Using restraints on the client to prevent a fall
a) Placing the client in a bed with a bed alarm
A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching? a) keeping medications in clearly labeled containers b) using alternatives to chemical-based cleaning supplies c) reviewing hidden sources of lead in the household environment d) avoiding the use of alternative and complementary therapies
a) keeping medications in clearly labeled containers
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? a) Place throw rugs in high traffic areas. b) Install 60 watt light bulbs in stairways. c) Use night-lights in bedrooms and bathrooms. d) Discourage the client from ambulating unless absolutely necessary
c) Use night-lights in bedrooms and bathrooms.
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? a) "I will rescue clients from harm before doing anything else." b) "After clients are evacuated from the room with the fire, the alarm can be sounded." c) "I will close the door to the room where the fire is after clients have been removed." d) "Only certain members of the health care team can extinguish a fire."
d) "Only certain members of the health care team can extinguish a fire."
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? A) "Check breathing and heart rate." B) "What do you think that the child might have ingested?" C) "At what time did the child ingest the substance?" D) "Induce vomiting while you wait for emergency personnel to arrive."
A) "Check breathing and heart rate."
A nurse is caring for an older adult client who has expressed concern regarding their decreased level of mobility, particularly walking around the house. Which question by the nurse is most appropriate to gain more information related to the client's safety at home? A) "Have you fallen down at all in the last few months?" B) "Do you have anyone that can help you at home?" C) "Do you use a cane or a walker at home?" D) "Do you have any throw rugs in the home?"
A) "Have you fallen down at all in the last few months?"
The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: A) "I should be able to fit two fingers between my chin and the chin strap." B) "The helmet should rest 1 in (2.5 cm) above the eyebrows." C) "My child needs a helmet if in a secured passenger bike seat." D) "My child should wear a helmet every time he rides a bike."
A) "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? A) "I will rescue clients from harm before doing anything else." B) "I will sound the alarm before I start moving a client from a room." C) "I will leave all doors open after rescuing clients." D) "I know that nurses are the only ones who can extinguish a fire."
A) "I will rescue clients from harm before doing anything else."
An 8-year-old child fell off their bicycle. They were not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions? A) "It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness." B) "Wearing bicycle helmets will keep your child safe from head injuries." C) "Concussions happen often in children of this age group, and they always bounce back fine." D) "Try to keep him resting for a few days at home using the television and his video games."
A) "It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness."
A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important? A) "Make sure that you have smoke detectors in your house and that they're in working order." B) "If your clothes should catch on fire, go to an open area as quickly as possible." C) "Make sure that your family's microwave oven was made after 1999; otherwise, it may be a fire risk." D) "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."
A) "Make sure that you have smoke detectors in your house and that they're in working order."
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? A) 19-year-old male college student majoring in physics B) 25-year-old female who just accepted her first job C) 34-year-old male who does not use a seat belt D) 40-year-old female who is working two jobs
A) 19-year-old male college student majoring in physics
An older adult client in the hospital has been deemed a risk for falls. What falls prevention measure should the nurse prioritize? A) Anticipate the client's need to urinate and assist to the toilet as appropriate B) Administer chemical sedation as ordered to prevent agitation C) Obtain a standing order for restraints D) Organize care to allow for at least 8 hours of uninterrupted sleep each night
A) Anticipate the client's need to urinate and assist to the toilet as appropriate
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? A) Ask to examine the client alone in order to speak to her privately. B) Document the observed behaviors in the client's chart. C) Nothing, as it is none of the nurse's concern. D) Report the suspicions to the authorities.
A) Ask to examine the client alone in order to speak to her privately.
The nurse is caring for a new older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? A) Assess the need for assistance with ambulation. B) Apply a lap belt to assist with transfer C) Apply socks to the client's feet. D) Arrange furniture securely so that the client has something to hold on to.
A) Assess the need for assistance with ambulation.
A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? A) Childproofing the house B) Smoking cessation C) Safety equipment for playing sports D) Back to sleep guidelines
A) Childproofing the house
The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? A) Establish the nurse's role during a disaster B) Provide simple explanations to maximize client safety C) Identify the resources available for the nursing unit D) Notify the organization's leader that a disaster has been called
A) Establish the nurse's role during a disaster
A nurse on a medical unit recognizes the need to demonstrate the Institute of Medicine's focus on safety in clinical practice. Which action best demonstrates the skills necessary to meet this standard? A) Filling out an incident report accurately after a client went missing from the unit B) Appreciating the relationship between continuing education and client safety C) Understanding the functions of a new automated intravenous pump that has been introduced to the unit D) Valuing the contributions of clients and their families who suggest possible improvements in care
A) Filling out an incident report accurately after a client went missing from the unit
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? A) Identifying systemic factors on the unit that may have contributed to the event B) Reinforcing the standards for nursing care to staff members who were involved C) Ensuring that the client's nurse is held accountable and educated about best practice D) Communicating the potential consequences of the near miss to the client involved
A) Identifying systemic factors on the unit that may have contributed to the event
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? A) Investigate the possibility of discontinuing his or her catheter. B) Limit the resident's fluid intake in order to reduce his or her urge to void. C) Collaborate with the resident's health care provider to have his or her diuretics discontinued. D) Increase the resident's physical activity to reduce evening restlessness.
A) Investigate the possibility of discontinuing his or her catheter.
A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? A) Involve family members in the client's care. B) Allow the client to use the bathroom independently. C) Keep the client sedated with tranquilizers. D) Maintain a high bed position so the client will not attempt to get out unassisted.
A) Involve family members in the client's care.
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? A) Provide a bedside commode and ensure adequate lighting. B) Obtain an order for insertion of an indwelling urinary catheter. C) Limit the client's fluid intake during the evening. D) Accompany the client to the bathroom every 4 hours around the clock.
A) Provide a bedside commode and ensure adequate lighting.
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? A) Report this sentinel event to the Joint Commission and to relevant state agencies B) Inform the public that the incident occurred, while protecting the confidentiality of the clients. C) File an incident report with the American Nurses Association describing plans for preventing similar events in the future. D) Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality.
A) Report this sentinel event to the Joint Commission and to relevant state agencies
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? A) Rescue anyone who is in immediate danger. B) Evacuate clients and staff. C) Activate the fire alarm on the unit. D) Attempt to extinguish the fire.
A) Rescue anyone who is in immediate danger.
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? A) Skeletal muscle paralysis that progresses symmetrically and in a descending manner B) Flu-like symptoms C) Skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic D) Petechial hemorrhages
A) Skeletal muscle paralysis that progresses symmetrically and in a descending manner
The nurse has identified the nursing concern of injury risk due to the use of assistive mobility devices in an unfamiliar environment. What outcome is most appropriate for this client's care plan? A) The client will demonstrate safety measures to prevent falls. B) The client will establish safety priorities with family members. C) The client will identify resources for safety information. D) The client will identify unsafe situations in their environment.
A) The client will demonstrate safety measures to prevent falls.
The home care nurse observes that a child has recently learned to ride a bicycle and is now riding independently. Which would the nurse teach the child about bicycle safety? A) The importance of being visible at night B) The importance of wearing a helmet or a sturdy headcovering C) The importance of never riding on the sidewalk D) The importance of using the buddy system
A) The importance of being visible at night
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: A) mass trauma terrorism. B) chemical terrorism. C) bioterrorism. D) nuclear terrorism.
A) mass trauma terrorism.
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. A) Infants should be rear-facing up to the age of 2 years. B) Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. C) Children over 30 lb (13.5 kg) only need a lap and shoulder belt. D) Infants should remain in the infant seat until the age of 2 years. E) A child may sit in the front seat when 8 years old
A, B
Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply. A) The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. B) The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. C) The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes. D) The nurse coordinator calls a meeting of all the health care professionals involved in the care of a client. E) The nurse uses the Internet to find new nursing techniques for the care of a client with cystic fibrosis. F) The nurse listens to a client who is having trouble adjusting to a long-term care facility and treats the client with compassion and respect.
A, B, C
Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. A) Use equipment only for the use for which it was intended. B) Only operate equipment the nurse is familiar with. C) Use three-pronged electric plugs whenever possible. D) Twist or bend electric cords to make sure the cords are not dragging on the floor. E) Clean all equipment with soap and water after use.
A, B, C
An older adult client in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply. A) "Did you experience dizziness prior to the fall?" B) "Can you tell what you were doing before you fell?" C) "Did you have pain in your hip prior to the fall?" D) "Did you attempt to get up without the assistance of staff?" E) "Is it possible you may have tripped over a rug or a cord?"
A, B, C, D, E
Which topics should be included in an education plan for preventing falls in the home? Select all that apply. A) Avoid climbing on a chair or table to reach items that are too high. B) Use a nightlight. C) Remove clutter from walkways. D) Keep electrical and telephone cords against the wall and out of walkways. E) Consider the use of a raised toilet seat. F) Consider the use of an electronic personal alarm.
A, B, C, D, E
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. A) Drowsiness B) Fever C) Headache D) Increased thirst E) Vomiting
A, C, E
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. A) Takes furosemide daily B) Admits to drinking wine through the evening C) Shares a one floor living space with a spouse D) Has history of diabetic neuropathy E) Participates in a walking club
A, B, D
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. A) Remove extension cords from open spaces. B) Check the batteries in all smoke detectors. C) Store prescription medications on the counter. D) Ensure appropriate lighting in hallways and entrances to the home. E) Remove throw rugs from high traffic areas.
A, B, D, E
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. A) Client-centered care B) Teamwork and collaboration C) Establishment of clinical career ladders D) Revamping the licensing requirements for foreign-educated nurses E) Quality improvement (QI)
A, B, E
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. a) Communication ability b) Community population c) Developmental level d) Mobility e) Type of health care facility
A, C, D
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. A) Obtain order from a licensed provider within minutes of restraint application. B) Withhold information from family regarding restraints due to HIPAA. C) Check circulation and skin condition every 2 hours. D) Offer regular, frequent opportunities for toileting. E) Maintain restraints until discharge.
A, C, D
The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply. A) Obtain a health care provider order 2 hours after restraints are applied. B) Communicate with the family regarding the need for restraints. C) Check circulation and skin condition frequently and regularly. D) Offer opportunities for toileting frequently and regularly. E) Continue using the restraints until discharge.
B, C, D
The nurse is discussing car safety with the parents of a 5-year-old child. The parents question the need for the use of special car seats for their child. What information should the nurse provide? A) "A forward-facing car seat is appropriate, in any of the vehicle's rear seating positions." B) "Your child should likely be using a booster seat." C) "Car seats are recommended until children are at least 10 years old." D) "Your child will be safe in the car using the provided shoulder harness and lap belts."
B) "Your child should likely be using a booster seat."
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? A) Assessment of head circumference B) Assessment of vital signs and respiratory status C) Evaluation of all of his cranial nerves D) Initiation of a peripheral intravenous (IV) line for fluid administration
B) Assessment of vital signs and respiratory status
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? A) Step in front of the client so that the other client will be protected. B) Call for assistance to remove the client from the area. C) Forcefully remove the client and place in four-point restraints. D) Inject the client while being restrained with antipsychotic medication.
B) Call for assistance to remove the client from the area.
Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority? A) Extinguish the fire. B) Rescue the client. C) Raise an alarm. D) Confine the fire.
B) Rescue the client.
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? A) Sedate her with sleeping pills and leave the restraints on. B) Take the restraints off, stay with her, and talk gently to her. C) Leave the restraints on and talk with her, explaining that she must calm down. D) Talk with the client's family about taking her home because she is out of control.
B) Take the restraints off, stay with her, and talk gently to her.
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? A) application of devices that reduce the client's ability to move arms B) administration of an antipsychotic agent to alter the client's behavior C) asking the unlicensed assistive personnel (UAP) to sit with the client D) articulating the reason for use of a physical restrictive device to the client's spouse
B) administration of an antipsychotic agent to alter the client's behavior
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: A) falls from beds. B) automobile accidents. C) play-related injuries. D) falls from staircases.
B) automobile accidents.
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? A) "Your home needs to be a safe environment as older adults have a tendency to fall." B) "I think you should replace your small rugs with skid-resistant rugs on the floor." C) "I am concerned that the small rugs in your home can be a tripping hazard." D) "You need to remove the small rugs from your house or you will fall."
C) "I am concerned that the small rugs in your home can be a tripping hazard."
The nurse has provided a family with education related to car seat safety for a 9-month-old infant. Which statement indicates an understanding of the teaching? A) "We place our infant in a front-facing car seat in the middle of the back seat of the car." B) "We place our infant in a front-facing car seat in the front of the car so that they do not cry." C) "We place our infant in a rear-facing car seat in the back seat of the car." D) "We place our infant in a rear-facing car seat in the front of the car so that we can see them in case of choking."
C) "We place our infant in a rear-facing car seat in the back seat of the car."
A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first? A) "Has this, or something very similar, ever happened on the unit before?" B) "Why did the second nurse administer this drug to the client?" C) "What could the two nurses have done to ensure this did not happen?" D) "What were the possible adverse outcomes that could have resulted from this error?"
C) "What could the two nurses have done to ensure this did not happen?"
A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which is the nurse's most appropriate initial action? A) Notify the primary care provider about the bruises. B) Contact the facility's social work department. C) Question the client about the source of the bruises. D) Request permission from the client to photograph the bruises
C) Question the client about the source of the bruises.
A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? A) The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. B) The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment. C) The nurse researches best current practices for prevention of the spread of infection in health care provider offices. D) The nurse uses computer-generated care plans for client care.
C) The nurse researches best current practices for prevention of the spread of infection in health care provider offices.
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? A) transferring the client from one location in the hospital to another B) electronically reporting the results of diagnostic testing to the client's primary care provider C) administering medications to the client D) admitting the client to the health care facility
C) administering medications to the client
The nurse considers applying restraints to an agitated client. Which action should the nurse take first? A) Assess the client for existing injuries to the wrists and hands. B) Ensure the client cannot reach any objects in the room. C) Call a family member to come and sit with the client. D) Dim the lights and speak softly about something the client enjoys.
D) Dim the lights and speak softly about something the client enjoys.
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? A) Mummy restraint B) Elbow restraint C) Waist restraint D) Extremity restraint
D) Extremity restraint
The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion? A) Inform the parent that abuse is suspected. B) Because the nurse is not sure, observation of the parents behavior will be done. C) Call the police. D) Notify the National Abuse Hotline.
D) Notify the National Abuse Hotline.
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? A) Leave to notify the health care provider concerning a change in client status B) Apply limb restraints to ensure client safety C) Promptly document the change in client status D) Reduce distressing environmental stimuli to maximize client safety
D) Reduce distressing environmental stimuli to maximize client safety
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? A) Respond to the past history of the client (including previous falls) to determine the need for restraints. B) Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. C) Individualize the use of restraints and choose the most easily used device. D) 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.
D) 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.
