Today 2 Safety - questions

Place the steps for conducting a Get Up and Go test in the proper order. 1. Turn around. 2. Stand still and then walk 10 feet. 3. Stand up from chair. 4. Sit down. 5. Turn around and walk back to chair.

3, 2, 5, 1, 4 This is the correct order for conducting a Get Up and Go test.

The nurse demonstrates an understanding of patient-centered care when: A. being careful to use costly dressing supplies appropriately but with their cost in mind. B. discussing the client's wish to include herbal preparations to treat an illness. C. promptly medicating clients when they request their prn analgesic. D. referring to evidence-based practice when planning client care.

B Patient-centered care involves providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Efficient care includes avoiding waste, effective care is based on scientific knowledge, and timely care focuses on reducing waits and delays in care delivery.

A patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint. Which type of restraint is most appropriate in this situation? 1. Mummy restraint 2. Elbow restraint 3. Jacket restraint 4. Mitt restraint

1. A mummy restraint usually is used to immobilize an infant or very young child during a procedure. 2. An elbow restraint usually is used to prevent flexion of the elbow in an infant or young child to prevent the pulling out of tubes. 3. A jacket restraint usually is used to keep a person from falling out of bed while not immobilizing the extremities. 4. CORRECT: A mitt restraint covers the hand to prevent the fingers from grasping and pulling out tubes.

A 3-year-old child is admitted to the pediatric unit. What is the best way for the nurse to maintain the safety of this preschool-aged child? 1. Teaching the child how to use the call bell 2. Placing the child in a crib with high side rails 3. Keeping the child under constant supervision 4. Having the child stay in the playroom most of the day

1. A preschool-aged child does not have the cognitive and emotional maturity to use a call bell. 2. A preschool-aged child might attempt to climb over the side rails. A crib with high side rails is more appropriate for an infant. 3. CORRECT: Constant supervision ensures that an adult can monitor the preschool-aged child's activity and environment so that safety needs are met. Preschool-aged children are active, curious, and fearless and have immature musculoskeletal and neurological systems, narrow life experiences, and a limited ability to understand cause and effect. All of these factors place preschool-aged children at risk for injury unless supervised. 4. This is inappropriate because most preschoolers still take one or two naps daily, the child may be on bed rest, and periods of activity and rest should be alternated to conserve the child's energy.

A nurse educator is teaching a group of newly hired nursing assistants. Which patient should they be taught is at the greatest risk for injury? 1. School-aged child 2. Comatose teenager 3. Postmenopausal woman 4. Confused middle-aged man

1. Although a school-aged child is at risk for injury in a hospital setting, age-related precautions are always instituted. More nurses generally are assigned to pediatric units and frequently family members are at the bedside. 2. This patient is not at as high a risk for injury as a patient in another option. A comatose patient demonstrates less response to painful stimuli, generally has an absence of muscle tone and reflexes in the extremities, and appears to be in a deep sleep. 3. A postmenopausal woman is not at a high risk for injury. 4. CORRECT: A confused patient is at an increased risk for injury because of the inability to comprehend cause and effect and, therefore, lacks the ability to make safe decisions.

What should the nurse do to best prevent a patient from falling? 1. Provide a cane 2. Keep walkways clear of obstacles 3. Assist the patient with ambulation 4. Encourage the patient to use the handrails in the hall

1. The patient may or may not need a cane. An unnecessary cane may actually increase the risk of a fall. 2. Although this should be done, it is not the best intervention of the options presented. 3. CORRECT: This widens the patient's base of support, which improves balance and decreases the risk of a fall. 4. Although this should be done, it is not the best intervention of the options presented

A nurse is caring for a patient with Parkinson's disease who is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care? 1. Anorexia 2. Aspiration 3. Self-care deficit 4. Inadequate intake

1. Although lack of an appetite (anorexia) can occur with dysphagia, it is not the most serious associated risk. 2. CORRECT: When a person has difficulty with swallowing (dysphagia), food or fluid can pass into the trachea and be inhaled into the lungs (aspiration) rather than swallowed down the esophagus. This can result in choking, partial or total airway obstruction, or aspiration pneumonia. 3. Dysphagia is unrelated to self-care deficit. Feeding self-care deficit occurs when a person is unable to cut food, open food packages, or bring food to the mouth. 4. Inadequate intake of food and fluid can result with dysphagia because of fear of choking. However, it is not the most serious associated risk.

A patient has dysphagia. Which nursing action takes priority when feeding this patient? 1. Ensuring that dentures are in place 2. Medicating for pain before providing meals 3. Providing verbal cueing to swallow each bite 4. Checking the mouth for emptying between every bite

1. Although this should be done if a patient has dentures, it is not the priority. 2. Although an analgesic may be administered, it can cause drowsiness that may increase the potential for aspiration in a patient with dysphagia. 3. Although this should be done, the patient may be physically incapable of following this direction. 4. CORRECT: This is the safest way to ensure that a bolus of food is not left in the mouth where it can be aspirated and cause an airway obstruction.

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in the program? 1. Wet floors 2. Frequent seizures 3. Advanced age of patients 4. Misuse of equipment by nurses

1. Although wet floors can contribute to falls, they are not the most common factor that contributes to falls in the hospital setting. 2. Although seizures can contribute to falls, most patients do not experience seizures. 3. CORRRECT: Older adults who are hospitalized frequently have multiple health problems, are frail, and lack stamina. All of these factors contribute to the inability to maintain balance and ambulate safely. 4. Although this occasionally happens and is negligence, it is not the most common factor that contributes to falls in the hospital setting.

The nurse is preparing a patient for a physical examination. What is most important for the nurse to do in this situation? 1. Identify the positions that may be contraindicated for the patient during the examination 2. Explore the patient's attitude toward health-care providers 3. Inquire about the other professionals caring for the patient 4. Ask when the patient last had a physical examination

1. CORRECT: A physical examination requires a patient to assume a variety of positions such as supine, side-lying, sitting, and standing. The nurse should inquire about any positions that are uncomfortable or contraindicated because of past or current medical conditions to prevent complications. 2. Although this information may be obtained during the course of the physical examination, it is not the priority. 3. This is not the priority during a physical examination. This might be done to prevent fragmentation of care and ensure continuity of care. 4. Although this might be done, it is not a priority during a physical examination.

A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug? 1. Controls stray electrical currents 2. Promotes efficient use of electricity 3. Shuts off the appliance if there is an electrical surge 4. Divides the electricity among the appliances in the room

1. CORRECT: A three-pronged plug functions as a ground to dissipate stray electrical currents. 2. This is not the purpose of a three-pronged plug. 3. A surge protector performs this function. 4. A multiple outlet plug performs this function.

Which is the first action the home care nurse should employ to prevent falls by an older adult living at home? 1. Conduct a comprehensive risk assessment 2. Encourage the patient to remove throw rugs in the home 3. Suggest installation of adequate lighting throughout the home 4. Discuss with the patient the expected changes of aging that place one at risk

1. CORRECT: Assessment is the first step of the Nursing Process. The best way to prevent falls is by identifying those at risk and instituting interventions that prevent falls. 2. This is just one strategy. A thorough assessment must be conducted first. 3. This is just one strategy. A thorough assessment must be conducted first. 4. This is just one strategy. A thorough assessment must be conducted first.

The practitioner orders a vest restraint for a patient. What should the nurse do first when applying this restraint? 1. Perform an inspection of the patient's skin where the restraint is to be placed 2. Ensure that the back of the vest is positioned on the patient's back 3. Permit four fingers to slide between the patient and the restraint 4. Secure the restraint to the bed frame using a slipknot

1. CORRECT: Even when applied correctly, restraints can cause pressure and friction. A baseline assessment of the skin under the restraint should be made. In addition, the presence of a dressing, pacemaker, or subclavian catheter may influence the type of restraint to use. 2. Although this is done, it is not the first intervention. 3. This will result in the jacket being too loose. The jacket should be applied so that two, not four, fingers can slide between the patient and the restraint. 4. Although this is done, it is the last, not the first, intervention of the options offered.

The nurse is orienting a newly admitted patient to the hospital. It is most important for the nurse to teach the patient how to: 1. Notify the nurse when help is needed 2. Get out of the bed to use the bathroom 3. Raise and lower the head and foot of the bed 4. Use the telephone system to call family members

1. CORRECT: Explaining how to use a call bell meets safety and security needs. It reinforces that help is immediately available at a time when the patient may feel physically or emotionally vulnerable in an unfamiliar environment. 2. Patients generally do not need teaching about how to get out of bed to go to the bathroom. This instruction depends on the individual needs of a patient. 3. Although this is part of orienting a patient to the hospital environment, it is not the most important point to emphasize with a patient. 4. Although this is part of orienting a patient to the hospital environment, it is not the most important point to emphasize with a patient.

Which actions are important when the nurse uses a stretcher? Select all that apply. 1. _____ Lowering the bed below the level of the stretcher when transferring a patient from the stretcher to a bed 2. _____ Guiding the stretcher around a turn leading with the end with the patient's head 3. _____ Ensuring the patient's head is at the end with the swivel wheels 4. _____ Pulling the stretcher on the elevator with the patient's feet first 5. _____ Pushing the stretcher from the end with the patient's head

1. CORRECT: Keeping a bed lower than a stretcher when transferring a patient from the stretcher to a bed uses gravity, which places less stress and strain on both the patient and nurses. 2. It is too difficult and unsafe to maneuver a stretcher with the nonswivel wheels on the leading end of the stretcher. The end of the stretcher with the patient's head does not have swivel wheels. 3. The swivel-wheeled end of the stretcher should be the leading end of the stretcher, and it is unsafe to lead with the patient's head. In addition, the end of the stretcher with the swivel wheels moves through greater arcs; this can cause dizziness. The swivel wheels of a stretcher should be at the end under the patient's feet, not the head. 4. This is unsafe and places the patient in physical jeopardy. The elevator doors may inadvertently close by the patient's head while the nurse is pulling the feet end of the stretcher into the elevator. The patient should be moved into an elevator head, not feet, first. 5. CORRECT: The swivel wheels must be under the patient's feet on the leading end of the stretcher for safe maneuverability. A stretcher should always be pushed, not pulled, so that the transporter stays at the patient's head for protection.

What clinical manifestation indicates that a further nursing assessment is necessary to determine if the patient is having difficulty swallowing? 1. Debris in the buccal cavity 2. Abdominal cramping 3. Epigastric pain 4. Constipation

1. CORRECT: Stasis of food in the oral cavity indicates that the patient is not swallowing ingested food completely. Food collects in the buccal cavity because the area between the teeth and cheek forms a pocket that traps the food. 2. Abdominal cramping is related to problems such as flatus, malabsorption, and increased intestinal motility, not difficulty swallowing. 3. Epigastric pain is related to problems, such as gastritis, cholecystitis, and angina, not difficulty swallowing. 4. Although constipation may result from not eating foods high in fiber because of difficulty with chewing and swallowing, this adaptation is not as directly related to difficulty swallowing as another option.

The nurse must apply a hospital gown that does not have snaps on the shoulders to a patient receiving an intravenous infusion in the forearm. What should the nurse do? 1. Insert the IV bag and tubing through the sleeve from inside of the gown first 2. Disconnect the IV at the insertion site, apply the gown, and then reconnect the IV 3. Close the clamp on the IV tubing no more than 15 seconds while putting on the gown 4. Don the gown on the arm without the IV, drape the gown over the other shoulder, and adjust the closure behind the neck

1. CORRECT: This ensures that the IV bag and tubing are safely passed through the armhole of the gown before the patient puts the arm with the insertion site through the gown. This prevents tension on the tubing and insertion site, which limits the possibility of the catheter dislodging from the vein. 2. Disconnecting the IV tubing at the catheter insertion site is unsafe. This opens a closed system unnecessarily, increasing the potential for infection. 3. This is unsafe. This stops the flow of the IV solution, which can result in blood coagulating at the end of the catheter in the vein and compromising the patency of the IV tubing. 4. This leaves the patient exposed unnecessarily. It interferes with privacy, and the patient may feel cold.

A nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. Which factor that most commonly causes injuries in hospitalized patients should be included in the teaching plan? 1. Malfunctioning equipment 2. Failure to use restraints 3. Visitors 4. Falls

1. Malfunctioning equipment is not a common cause of injuries in a hospital. 2. The use of restraints has declined dramatically and now is used only when patients may harm themselves or others. 3. Visitors are not the main cause of injuries in a hospital. 4. CORRECT: Research demonstrates that most injuries experienced by hospitalized patients occur from falls. Failing to call for assistance, inadequate lighting, and the physical condition of the patient all contribute to falls.

Which human response to illness alerts the nurse that a patient has the greatest risk for aspiration during meals? 1. Bulimia 2. Lethargy 3. Anorexia 4. Stomatitis

1. The risk for aspiration in a patient with bulimia occurs after, not during, meals. Bulimia is characterized by episodes of binge eating followed by purging, depression, and self-deprecation. 2. CORRECT: When a person is sleepy, sluggish, or stuporous (lethargic), there may be a reduced level of consciousness and diminished reflexes, including the gag and swallowing reflexes. This condition can result in aspiration of food or fluids that can compromise the person's airway and respiratory status. 3. A lack of appetite (anorexia) is unrelated to aspiration. The less food or fluid that is placed in the mouth, the less the risk for aspiration. 4. An inflammation of the mucous membranes of the mouth (stomatitis) may result in dysphagia and increase the risk of aspiration. However, of the options offered, it does not place a person at the greatest risk for aspiration.

Which time of day is of most concern for the nurse when trying to protect a patient with dementia from injury? 1. Afternoon 2. Morning 3. Evening 4. Night

1. The sunlight and usual afternoon activities generally help keep patients with dementia more oriented and safe. 2. The sunlight and the routine morning activities of hygiene, grooming, dressing, and eating generally help keep patients with dementia more oriented and safe. 3. As the day progresses and the sun sets, the concern for safety increases because of altered cognition (sundowner syndrome). However, in the evening there are activities of daily living and available caregivers to distract the patient and provide for safety. 4. CORRECT: At night, patients with dementia often continue to experience confusion and agitation. At night there is less light, less activity, and fewer caregivers, so there are fewer orienting stimuli. Patients who are confused or agitated are at an increased risk for injury because they may not comprehend cause and effect and, therefore, lack the ability to make safe judgments.

What is an appropriately worded goal for a patient who is at risk for falling? "The patient will be: 1. Taught how to call for help to ambulate." 2. Kept on bed rest when dizzy." 3. Restrained when agitated." 4. Free from trauma."

1. This is a planned intervention, not a goal. 2. This is a planned intervention, not a goal. 3. This is a planned intervention, not a goal. In addition, it is inappropriate to restrain a person automatically for agitation. A restraint should be used as a last resort to prevent the patient from self-injury or injuring others. 4. CORRECT: This is an appropriate goal. It is realistic, specific, and measurable and has a time frame. It is realistic to expect that all patients be safe. It is specific and measurable because safety from trauma can be compared with standards of care within the profession of nursing. It has a time frame because the words free from reflect the time frames of always, constantly, and continuously.

Profuse smoke is coming out of the heating unit in a patient's room. What should the nurse do first? 1. Open the window 2. Activate the fire alarm 3. Move the patient out of the room 4. Close the door to the patient's room

1. This is contraindicated because environmental air will feed the fire, causing it to increase in severity. 2. Although this will be done, it is not the priority at this point in time. 3. CORRECT: The patient's physical safety is the priority. The patient must be removed from direct danger before the alarm is activated and the fire contained. 4. Although this will be done eventually, it is not the priority at this point in time.

The nurse is planning care for a patient who requires bilateral arm restraints. Which information is important to consider when planning care for this patient? 1. Their use adequately prevents injuries 2. They require a practitioner's order to be applied 3. Reasons for their use must be clearly documented 4. Most patients recognize that they contribute to their safety

1. This is not true. Injuries and falls can occur if restraints are not applied appropriately. In addition, research indicates that patients incur less severe injuries if left unrestrained. 2. In the case of the medical surgical care standard, restraints can be applied in emergencies to protect patients from harming themselves or others. A practitioner's order must be obtained within 12 hours after its application. Agencies have protocols concerning how often restraints need to be reordered by the practitioner (many require reorders every 24 hours). In the case of the behavior management standard, restraints may be applied in an emergency and a practitioner must evaluate the patient within 1 hour and every 4 hours thereafter. 3. CORRECT: All patient care, including the use of restraints, should adhere to standards of care. The reason for the use of restraints must adhere to standards of care and be documented on the patient's clinical record to create a legal document that protects the patient as well as the health-care providers. 4. The opposite is true. Patients resist the use of restraints and usually are mentally or emotionally incompetent to understand their necessity or benefits.

The nurse is caring for a patient with a nasogastric tube for gastric decompression. Which nursing action takes priority? 1. Discontinuing the wall suction when providing care 2. Positioning the patient in the semi-Fowler position 3. Instilling the tube with 30 mL of air every 2 hours 4. Caring for the nares at least every 8 hours

1. This is unnecessary and can result in vomiting and aspiration. 2. CORRECT: A nasogastric (NG) tube for gastric decompression passes down the esophagus, through the cardiac sphincter, and into the stomach. The cardiac sphincter remains slightly open because of the presence of the NG tube. The semi-Fowler position keeps gastric secretions in the stomach via gravity (preventing reflux and aspiration) and allows the gastric contents to be suctioned out by the NG tube. 3. This is not done routinely every 2 hours. This may be done to identify the presence of the tube in the stomach and help reestablish patency of the tube when it is clogged. 4. This should be done more frequently to prevent irritation and pressure.

The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range? 1. Once a shift 2. Once an hour 3. Every 2 hours 4. Every 4 hours

1. This is unsafe because it is too long a period, which promotes the development of contractures. 2. This generally is too often and unnecessary. 3. CORRECT: Restraints should be removed every 2 hours. The extremities must be moved through their full range of motion to prevent muscle shortening and contractures. The area must be massaged to promote circulation and prevent pressure injuries. 4. This is too long a period between activities and promotes the development of contractures.

A school nurse is teaching children about fire safety procedures. What is the first thing they should be taught to do if their clothes catch on fire? 1. Yell for help 2. Roll on the ground 3. Take their clothes off 4. Pour water on their clothes

1. This may eventually be done, but the child must do something immediately without waiting for help to arrive. 2. CORRECT: Rolling on the ground will smother the flames and put the fire out. Children should be taught to: "Stop, drop, and roll." 3. This may be impossible. In addition, it will take time and the clothing and skin will continue to burn. 4. Finding and obtaining water will take too much time and the clothing and skin will continue to burn. Something must be done immediately.

What is the priority nursing intervention to prevent patient problems associated with latex allergies? 1. Use nonlatex gloves 2. Identify persons at risk 3. Keep a latex-safe supply cart available 4. Administer an antihistamine prophylactically

1. This may or may not be necessary depending on the needs of the patient. 2. CORRECT: Patient allergies must be identified (e.g., latex, food, medication) before any care is provided, be documented in the patient's clinical record, and appear on an allergy-alert wristband. After a risk is identified, additional safety precautions can be implemented to prevent exposure to the offending allergen. Assessment is the first step of the Nursing Process. 3. This may be available but is useless unless the supplies are used appropriately. 4. This is unnecessary. A person with a latex allergy should not be exposed to products with latex.

What is the last step in making an occupied bed that the nurse should teach a nursing assistant? 1. Raising both the side rails on the bed 2. Lowering the height of the bed toward the floor 3. Ensuring that the patient is in a comfortable position 4. Elevating the head of the bed to a semi-Fowler position

1. This may or may not be necessary. This action should be based on the individual needs of the patient. 2. CORRRECT: It is safer if the bed is in the lowest position because a greater risk for injury to a patient occurs when the mattress of the bed is further from the floor. 3. This should be done while the bed is at a comfortable working height for the caregiver. 4. This may or may not be necessary. This action should be based on the individual needs of the patient.

The nurse is preparing a bed to receive a newly admitted patient. Which action is most important? 1. Place the patient's name on the end of the bed 2. Ensure that the bed wheels are locked 3. Position the call bell in reach 4. Raise one side rail

1. This violates the patient's right to privacy. An identification wristband must be worn for patient identification. 2. CORRECT: Locked bed wheels are an important safety precaution. The bed must be an immovable object because the patient may touch the bed for support, lean against it when getting in or out of bed, or move around when in bed. If the bed wheels are unlocked during these maneuvers, the bed may move and the patient can fall. 3. The call bell wire may become an obstacle when moving the patient into the bed. This should be done after the patient is in the bed. 4. The side rail may become an obstacle when moving the patient into the bed. This should be done after the patient is in the bed.

What is the proper order for applying a wrist restraint? 1. Pad the skin overlying the wrist. 2. Insert two fingers under secured restraint to be sure that it is not too tight. 3. Be sure that patient is comfortable and in correct anatomical alignment. 4. Secure restraint straps to bed frame with quick-release buckle. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.

3, 1, 5, 2, 4 This is the proper order for applying a wrist restraint.

Health care institutions are automatically approved by The Centers for Medicare & Medicaid Services (CMS) when they: A. have earned The Joint Commission (TJC) accreditation. B. demonstrate their commitment to quality improvement. C. incorporate ORYX® performance measurements into their goals. D. provide care to a substantial number of Medicare and Medicaid clients.

A Health care organizations that are accredited by TJC automatically meet foundational approval from the CMS. The other options are not true regarding CMS approval.

It is true that quality improvement: A. is proactive rather than reactive. B. is reliant on administration to problem solve. C. looks for problems rather that plans to prevent problems. D. relies on a few specially trained individuals to take responsibility.

A It is true that quality improvement is proactive, looking for and anticipating problems rather than reacting once a problem is identified. The other options are reflective of quality assurance rather than quality improvement.

A young mother asks the nurse in the outpatient clinic what causes toddlers to often have accidents. Which of the following statements made by the nurse best answers the mother's question? A. "Toddlers are curious about their surrounding environment." B. "The toddler's environment expands." C. "Toddlers take risks frequently." D. "Many toddlers are exposed to stress in their daily activities."

A Toddlers begin to explore because of curiosity about their environment. School-age children are at risk because their world expands as they begin to go to school and interact with more children. Adolescents are the age-group that often engages in risk taking. Adults tend to have accidents because of their reaction to stress introduced into daily activities.

Positioning a hemiplegic patient in Fowler's position will increase the patient's: (Select all that apply.) A. Ventilatory capacity. B. Cardiac output. C. Ability to swallow. D. Risk of aspiration.

A, B, C Fowler's position increases ventilation and cardiac output and improves the patient's ability to swallow. Answer "D" is incorrect; Fowler's position helps to prevent aspiration of food, liquids, and gastric secretions.

In creating a culture of home care safety, the nurse will consider which of the following? (Select all that apply.) A. Concern for the health care provider's safety B. Surrounding neighborhoods C. Age of the client D. Role of caregivers in the family E. Physical layout of the home

A, B, C, D, E Creating a culture of home care safety takes into account the client and family caregivers, but also the health care provider. All parties need to feel secure and safe. In addition, the physical environment within and outside the home is of concern, and, in relation to culture, the role of the caregiver must be considered. In some cultures, the direct caregiver is a family member, and the family may not look favorably on an outsider, such as the health care provider.

Which of the following activities reflect a culture of safety within a health care organization? (Select all that apply.) A. A hospital purchases a new bar-code system to check patient identification during medication administration. B. A hospital requires nurse managers to submit an annual safety plan for high-risk patients. C. A nurse commits an error while administering a high-risk medication and is released from her position. D. A hospital enforces routine monthly checks of electrical equipment.

A, B, D A culture of safety includes a commitment that acknowledges the high-risk nature of the activities of an organization (i.e., manager's safety plan, the determination to achieve consistently safe operations [check of electrical equipment], and an organizational commitment to resources [purchase bar-code system]). A blame-free environment is also characteristic.

A physician writes an order for restraining a patient. What information would the nurse expect to find in the order? (Select all that apply.) A. The time limitation for application of the restraint B. The type of restraint to be applied C. Alternative strategies to be used before a restraint is used D. A list of behaviors that require use of restraints E. The documentation required while the patient is restrained F. Instructions to notify the patient's next of kin that restraints were applied

A, B, D The facility would outline the alternative strategies that should be tried before restraints are used. Instruction in documentation would be provided before restraints are ordered. It is not required to notify the patient's next of kin when restraints are applied.

Which of the following patients are at risk for falls because of intrinsic factors? (Select all that apply.) A. A patient with a tendency to have postural hypotension B. A patient whose hospital room has a bedside commode and suction machine blocking the path to the bathroom C. A patient who has bathroom floor mats that are thin and frayed D. A patient who suffers dementia and has cataracts

A, D Intrinsic fall factors are physiological conditions such as postural hypotension that causes poor balance, dementia, and visual deficits (cataracts). The other answers are examples of extrinsic fall factors (i.e., those that are environmentally related).

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following. A. Hypotension B. Bradycardia C. Clammy Skin D. Bradypnea

A. CORRECT: A clinical manifestation of heat stroke is hypotension B. INCORRECT: A clinical manifestation of heat stroke is tachycardia, not bradycardia. C. INCORRECT: A clinical manifestation of heat stroke is hot, dry skin, not clammy skin D. INCORRECT: A clinical manifestation of heat stroke is tachypnea, not bradypnea.

A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A. Complete a fall-risk assessment B. Educate the client and family on fall risks. C. Complete a physical assessment. D. Survey the client's belongings.

A. CORRECT: The greatest risk to this client is injury due to a fall. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures. B. INCORRECT: It is important for family members to be aware of the client's risk for falls. Providing instruction to the client and family is an appropriate nursing action, but this is not the priority action. C. INCORRECT: Competing a physical assessment will help you to identify further risk for injury and provide baseline physical data, but this is not the priority action. D. INCORRECT: Surveying the client's belongings (glasses, medications, hearing aids, canes, walkers) may provide clues to potential fall risks. However, this is not the priority action.

Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? A. Providing adequate lighting B. Raising the pitch of the voice C. Holding onto the patient's arm D. Removing environmental hazards

A. CORRECT: This provides for the safety of patients, staff, and visitors within a hospital. Inadequate lighting causes shadows, a dark environment, and the potential for misinterpreting stimuli (illusions), and is a major cause of accidents in the hospital setting. B. INCORRECT: When talking with older adults it is better to lower, not raise, the pitch of the voice. As people age they are more likely to have impaired hearing with higher pitch sounds C. INCORRECT: This is not always necessary and therefore could be degrading or promote regression. D. INCORRECT: Although this should be done, furniture and medical equipment are not the only physical hazards that contribute to falls.

The nurse is caring for a confused patient. To prevent this patient from falling, the nurse should: A. Encourage the patient to use the corridor handrails B. Place the patient in a room near the nurses' station C. Reinforce how to use the call bell D. Maintain close supervision

A. INCORRECT: A confused patient may not be able to follow directions or understand cause and effect. B. INCORRECT: This may be impossible and impractical. C. INCORRECT: A confused patient may not be able to follow directions or understand cause and effect. D. CORRECT: Maintaining safety of the confused patient is best accomplished through close or direct supervision. Confused patients cannot be left on their own because they may not have the cognitive ability to understand cause and effect, and therefore their actions can result in harm.

A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A. Extinguish the fire. B. Pull the fire alarm. C. Evacuate the clients. D. Close all doors on the unit.

A. INCORRECT: Although extinguishing the fire is part of the fire response, it is not the priority action. B. INCORRECT: Although pulling the fire alarm is part of the fire response, it is not the priority action. C. CORRECT: Rescue is the first action in the fire response. Protecting and evacuation clients in close proximity to the fire is the priority action. D. INCORRECT: Although containing the fire by closing the doors is part of the fire response, it is not the priority action.

A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following client's should be assigned to the room closest to the nurse's station? A. A 43-year old client who is post operative following a laparoscopic cholecystectomy. B. A 61-year old client being admitted for telemetry to rule out myocardial infarction. C. A 50-year old client who is postoperative following an open reduction internal fixation of the ankle D. A 79-year old client who is post operative following a below-the-knee amputation.

A. INCORRECT: Although this client just had surgery, risk factors for falls are low based on the client's age and type of surgery. B. INCORRECT: Although this client is on telemetry, this client does not display as many risk factors as another client who is to be admitted. C. INCORRECT: Although this client just had surgery, this client does not display as many risk factors as another client who is to be admitted. D. CORRECT: This client should be assigned to a room near the nurses' station due to risk factors that include client's age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication.

The nurse is assessing a patient who is being admitted to the hospital. Which is the most important information collected by the nurse that indicates whether the patient is at risk for physical injury? A. Weakness experienced during a prior admission B. Medication that increases intestinal motility C. Two recent falls that occurred at home D. The need for corrective eyeglasses

A. INCORRECT: Although this is important information, it is not the most important factor of the options offered in this question. In addition, the prior admission may have been too long ago to have any current relevance. B. INCORRECT: A patient with increased intestinal motility may experience diarrhea, which may place the patient at risk for a fluid and electrolyte imbalance, not a physical injury. Although a person with diarrhea may need to use the toilet more frequently, a bedside commode or bedpan can be used to reduce the risk of falls C. CORRECT: This is significant information that must be considered because if falls occurred before, they are likely to occur again. When a risk is identified, additional injury prevention precautions can be implemented. D. INCORRECT: Although this is important information, it is not the most important factor of the options offered in this question

A patient states that when turning on an electric radio a strong electrical shock was felt. What should the nurse do first? A. Arrange for the maintenance department to examine the radio B. Disconnect the radio from the source of energy C. Check the skin for electrical burns D. Take the patient's apical pulse

A. INCORRECT: Although this may be done eventually, it is not the priority at this time. B. INCORRECT: This action is contraindicated because it may place the nurse in jeopardy. C. INCORRECT: This is not the priority, and electrical burns may or may not be evident. D. CORRECT: An electric shock can interfere with the electrical conduction system within the heart and result in dysrhythmias. An electric shock can be transmitted through the body because body fluids (consisting of sodium chloride) are an excellent conductor of electricity.

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

A. INCORRECT: Carbon monoxide cannot be seen, smelled, or tasted. B. INCORRECT: Gas-burning furnaces, water heaters, and appliances should be inspected annually. C. INCORRECT: Although carbon monoxide reduces the amount of oxygen supplied to the body, the lungs are not damaged. D. CORRECT: Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.

A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of fall. (Select all that apply) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in low position with full side rails up. C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

A. INCORRECT: It is inappropriate to restrain this client and could be considered false imprisionment. B. INCORRECT: Full side rails for this client may put the client at greater risk for fall because he may attempt to climb over the bed rails to get out of bed. C. CORRECT: Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear may keep the client from slipping E. CORRECT: A fall-risk assessment serves as the basis for an individualized plan of care.

A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification and instruction. A. I will begin swimming lessons as soon as my baby can close her mouth under water. B. Once my baby can sit up, he should be safe in the bathtub. C. I will test the temperature of the water before placing my baby in the bathtub. D. Once my infant starts to push up, I will remove the mobile from over the bed.

A. INCORRECT: It is recommended to begin swimming lessons when the infant's developmental status allows for protective responses such as closing the mouth under water. B. CORRECT: Although the baby can hold his head above the water by sitting up, this does not make the child safe in the bathtub. Parents should never leave an infant or toddler alone in the bathtub. C. INCORRECT: It is recommended to test the temperature of bath water prior to placing an infant in the bath. D. INCORRECT: It is recommended to remove crib toys, such as mobiles, from over the bed as soon as the infant begins to push up.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complication from food poisoning. C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

A. INCORRECT: Most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella. B. CORRECT: Very young, very old, and immunocompromised individuals, as well as pregnant women, are at risk for complications from food poisoning. C. CORRECT: Clients who are especially at risk are instructed to follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, or other dairy products. D. INCORRECT: Healthy individuals usually recover from the illness in a few days. E. CORRECT: Performing proper hand hygiene, ensuring that meat and fish are cooked to the correct temperature, handling raw and fresh food separately to avoid cross contamination, and refrigerating perishable items may prevent food poisoning.

An unconscious patient begins vomiting. In which position should the nurse place the patient? A. Supine B. Side-lying C. Orthopneic D. Low-Fowler's

A. INCORRECT: The supine position will promote aspiration and should be avoided in this situation. B CORRECT: The side-lying position prevents the tongue from falling to the back of the oropharynx, allowing the vomitus to flow out of the mouth by gravity and thus preventing aspiration. C. INCORRECT: The orthopneic is an unsafe, impossible position in which to maintain an unconscious patient. D. INCORRECT: The low-Fowler's position will allow the tongue to fall to the back of the oropharynx, promoting aspiration. This position should be avoided in this situation.

The nurse is assisting a patient to use a bedpan. What is the most important nursing intervention? A. Dusting powder on the rim before placing the bedpan under the patient B. Positioning the rounded rim of the bedpan toward the front of the patient C. Ensuring that the bedside rails are raised once the patient is on the bedpan D. Encouraging the patient to help as much as possible when using the bedpan

A. INCORRECT: The use of powder should be avoided because it is a respiratory irritant. B. INCORRECT: The rounded rim of a bedpan should be placed under the patient's buttocks, not toward the front of the patient. C. CORRECT: Patient safety is a priority. A bedpan is not a stable base of support and the effort of elimination may require movements that alter balance. Side rails provide a solid object to hold while balancing on the bedpan and supply a barrier to prevent falling out of bed. D. INCORRECT: Although this is done to promote independence and limit strain on the nurse, it is not the most important factor to consider when assisting a patient with a bedpan

A toaster is on fire in the pantry of a hospital unit. The nurse should first: A. Unplug the toaster B. Activate the fire alarm C. Put out the fire with an extinguisher D. Evacuate patients from the room next to the kitchen

A. INCORRECT: This is unsafe because it places the nurse in jeopardy. The nurse may be exposed to an electrical charge or become burned. B. CORRECT: Because no patient is in jeopardy, the nurse's initial action should be to activate the alarm. The sooner the alarm is set, the sooner professional firefighters will reach the scene of the fire. C. INCORRECT: The nurse may not be capable of containing or fighting the fire. Not calling for professional firefighting help first places the nurse, staff, and patients in jeopardy. D. INCORRECT: This is premature at this time, but it may become necessary eventually

A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. I will go to the nurses' station for assistance." C. I will administer medications as prescribed. D. I will be prepared to insert an airway.

A. INCORRECT: When a seizure occurs, the client should be placed in a side-lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. B. CORRECT: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light. C. INCORRECT: Administering medications is an appropriate action by the nurse. D. INCORRECT: Nothing should be placed in the client's mouth except an airway, if needed. A tongue blade can cause injury and airway obstruction.

A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply) A. Family members who smoke must be at least 10 feet from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "no smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

A. INCORRECT: family members who smoke should do so outside B. CORRECT: Nail polish and other flammable materials may cause a fire and should not be used. C. CORRECT: A "no smoking" sign should be placed near the front door. A sign also may be placed on the client's bedroom door. D. INCORRECT: Woolen and synthetic materials create static electricity; cotton materials do not and should be used instead. E. CORRECT: A readily available fire extinguisher should be placed in all homes, including the home of a client who is receiving oxygen.

The nurse identifies the presence of a fire in the dirty utility room. Place the nurse's actions in order of priority using the RACE model. 1. Pull the fire alarm 2. Close unit doors and windows 3. Shut the door to the utility room 4. Provide emotional support to agitated patients

Answer: 1, 3, 2, 4 1. Pulling the fire alarm ensures that appropriate hospital personnel and the fire department are notified of the fire. Trained individuals will arrive to contain and extinguish the fire and help move patients if necessary. The RACE model should be followed in a fire emergency: Rescue, Alarm, Confine, Extinguish) 3. Closing the door to the dirty utility room protects the patients and staff members in the immediate vicinity of the fire. 2. Closing unit doors and windows provides a barrier between the patients and the fire and limit drafts that could exacerbate the fire. 4. Patients should be supported emotionally during a crisis because anxiety can be contagious.

A patient with a proprioceptive disorder is being assessed for his ability to walk from bed to chair. You notice that the patient is bent forward and is leaning toward the right. Which nursing diagnosis would be the primary one on which to base his care? A. Activity intolerance B. Risk for injury C. Chronic pain E. Nutrition: less than body requirements

B A problem with proprioceptive function interferes with a person's awareness of his posture and changes in balance. Safety issues would be of primary concern during this patient's assessment and care.

When should discussions about home care safety take place? A. After the client has had a chance to settle back into his/her home B. While the client is still in the acute care setting C. Only with caregivers so as not to upset the client D. On the first full day home with the client

B Quality care dictates that home safety be discussed before the client is discharged, in the acute care setting. Insurance companies often limit home care coverage; therefore, you must make the most of all opportunities to communicate with client and family, and must not wait until there is an incident.

Upon visiting an elderly couple in their home, the nurse discovers that the wife is sharing her husband's antibiotic prescription. How should the nurse respond to this? A. Offer to refill the prescription so the couple does not run out of medication. B. Explain that taking someone else's medication is an unsafe practice. C. Report the incident to the local public health department. D. Ignore this information because it is not a matter of concern

B Sharing medications can be common for older adults who are on a fixed income and are concerned about medication costs. This is unsafe, however, and no one should take a medication that was not prescribed for him/her, even if it is received from a family member.

Which example of discharge teaching addresses a never event as identified by The Centers for Medicare and Medicaid Services? A. Food choices for a low-fat, low-carbohydrate diet B. Signs and symptoms of both hypo- and hyperglycemia C. Need for good medication compliance in managing schizophrenia D. Suggested exercise options for the immediate postdelivery period

B The manifestations of poor glycemic control has been identified as a never event by The Centers for Medicare and Medicaid Services. The other options, although they are appropriate subjects for discharge education for specific clients, do not address never events.

A nursing team conference is being held to discuss a patient who wanders frequently. The 72-year-old gets lost on the nursing unit and goes into other patients' rooms. The nursing team selects a set of interventions. Which of the following is not an appropriate restraint alternative? A. Arranging to have the patient work on a puzzle in her room B. When the patient becomes aggressive with other patients, confronting her and immediately removing her from the room C Relocating the patient to a room near the nurses' station D Asking the patient's family to bring pictures of grandchildren to place in the patient's room

B The proper way to deal with aggressive behavior is de-escalation and time-out. Confronting the patient and having her leave the room might increase her aggression.

Mr. Rosen is a 72-year-old patient who is scheduled for elective surgery. A review of his history shows that he takes a total of six medicines daily. He is generally healthy but has an enlarged prostate that causes him to go to the bathroom frequently. He had a low-grade fever the night before surgery but is afebrile at 7 AM. Which factors place him at a fall risk? (Select all that apply.) A. Low-grade fever B. Multiple medications C. Elective surgery D. Urinary frequency

B, D Known risk factors for falls do not include fever or elective surgery. However, if a patient develops a high fever and as a result becomes confused or disorientated or suffers electrolyte imbalance, risk for falls develops.

A nurse discovers an electrical fire in a patient's room. Which action should the nurse take first? A. Turn off the oxygen to the unit. B. Evacuate any patients/visitors in immediate danger. C. Close all doors and windows. D. Use the nearest fire extinguisher to put the fire out.

B. The first action is to rescue and remove all patients in immediate danger, then activate the alarm, confine the fire, and extinguish the fire.

Which nursing activity best demonstrates the quality management principle of "All One Team?" A. Encouraging clients to determine when they want their daily bath B. Doing a search of the literature regarding prevention of postoperative bleeding in smokers C. Asking a wound care team nurse how to best educate a client on wound prevention D. Attending a seminar on the latest recommended therapy to reinforce cognitive function in the elderly

C Demonstrating faith in the people who comprise the health care team and recognizing the expertise of particular team members reflects the "all one team" principle. Quality is demonstrated by considering clients as those who define whether their care is appropriate and of high value. Knowledge, especially when evidence based, demonstrates the scientific approach to client care.

The home care nurse is scheduled to visit a Mexican-American client who is newly diagnosed with cardiovascular disease for the first time. The nurse can expect the family to: A. Refuse to participate in care of the client. B. Cancel the scheduled home care visit. C. Assume care of the client themselves. D. Ask the nurse to place the client in a long-term care facility.

C Mexican-American families prefer to assume responsibility for the care of family members. The home care nurse needs to recognize this preference and must work with the client and family in planning and implementing care.

A home health nurse is visiting a patient and begins a discussion with the family caregiver about food safety. Which of the following statements made by the caregiver suggests that he or she requires further instruction? A. "When I prepare a salad, I need to rinse the lettuce and mushrooms thoroughly." B. "I always wash my hands before I start to make a meal." C. "When I make meat loaf, I use the cutting board to cut up onion and then shape the hamburger loaf on the same board." D. "I always cook my husband's pork chops well done."

C One should always use a separate cutting board for vegetables, poultry, and meat.

The client returns home from a lengthy hospital stay and finds that his family has rearranged the entire first floor of his home, moving his bedroom into the living room. The client reacts with anger toward the family, and the family is confused by his response. Which of the following statements should the nurse make to assist in dealing with this situation? A. (Whispering) To the family, "Don't worry, he will get used to the changes." B. To the family, "Didn't I tell you that your father would be unhappy with what you did?" C. To the client, "Tell me what it is about the changes that make you unhappy." D. To the client, "This new arrangement is much safer for you, so we need to keep it this way."

C Responding with "Tell me what it is about the changes that make you unhappy" acknowledges the client's distress and gives him an opening to verbalize concerns. Modifications to the home environment should be made only after consultation with the client and evaluation of his strengths and weaknesses. Making changes without his input may have taken away his sense of independence and autonomy. As the nurse, you must advocate for your client and work with the family

Two assistive personnel ask the nurse for assistance to transfer a patient from the bed to a stretcher using the three-person lift technique. What is the most appropriate response from the nurse? A. "As long as we use proper body mechanics, no one will get hurt." B. "Since the patient weighs only 100 pounds, you can handle the transfer yourselves." C. "Please find the slide board for us to use." D. "Which one of you wants to be at the patient's head?"

C The three-person lift for horizontal transfer from the bed to the stretcher is no longer recommended. Physical stress can be decreased significantly by the use of a slide board.

The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confused behavior. The patient says that she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Ask the physician or health care provider to order a restraint. B. Insert a urinary catheter. C. Provide scheduled toileting rounds every 2 to 3 hours. D. Consult with the health care provider about ordering an anti anxiety medication. E. Keep the bed in low position with the side rails down. F. Keep the pathway from the bed to the bathroom clear.

C, E, F Safety measures include checking on patients often and providing for toileting needs, keeping a bed in low position with side rails down to allow for easy exit, and keeping walking pathways clear. A restraint is not appropriate because the patient is not a threat to herself or care providers. Inserting a catheter increases risk for infection unnecessarily. Having a bedside commode would be a better option. Anti anxiety medication may not be indicated for the patient's condition.

A nurse is conducting a class on fall prevention for staff on the patient care unit. Which statement is appropriate to include in the presentation? A. Falls are most successfully prevented by making the patient's environment safe. B. Early use of restraints in a suddenly restless patient will effectively reduce falls. C. A bed alarm even when used alone will generally prevent falls in most patients. D. The fall prevention strategies used should be appropriate for the patient's behaviors.

D A safe environment is important, but the patient's behaviors and risks must be matched with the interventions to be used. Restraints are always a last resort and are not considered a safe fall prevention strategy. A bed alarm can be useful in fall prevention but should be combined with appropriate behavioral therapies.

A fire begins in the bathroom of a 200-pound (91-kg) patient who has a cast that extends from his hip to his ankle. What is the best method for evacuating this patient? A. Place him on a blanket on the floor, and drag him out of the room. B. Get another staff member to help using the two-person swing carry technique. C. Use the "back-strap" method to get him out of his room. D. Leave him in bed, and push the bed out of the room.

D Because of his weight and limited mobility, the most appropriate method for evacuating this patient is rolling his bed out of the room with him in it. The other methods would increase the risk for injury to the nurse(s) involved.

What is the safest position for a patient to assume after he has had a grand mal seizure? A. Supine with head elevated 90 degrees B. Reverse Trendelenburg's position C. Trendelenburg's position D. Side-lying position

D The side-lying position keeps the patient's head down so that aspiration cannot occur. Reverse Trendelenburg's position would increase aspiration risk. Trendelenburg's is not a safe position if the patient has a recurrence of the seizure. In the supine position, secretions that have collected in the throat will not drain as well from the mouth.

The patient is being log-rolled onto his right side. The patient's position would be correct if what assessment was observed? A. The patient is left in Sims' position. B. The patient is moved in a smooth, continuous motion. C. Two pillows are placed behind the patient's back while on his side. D. A straight line is evident from the shoulder to the hip.

D This answer focuses on the patient's position, which requires the vertebral column to be straight. No specified number of pillows are needed behind the patient's back.