ADN 140 - PrepU - Safe Practice 1

The American Nurses Association (ANA) identifies effective documentation using which of the following characteristics? (Select all that apply.) - Readable - Thoughtful - Timely, contemporaneous, and sequential. - Clear, concise, and complete - Accurate, relevant, and lengthy - Retrievable on a temporary basis.

- Readable - Thoughtful - Timely, contemporaneous, and sequential. - Clear, concise, and complete

A nurse is teaching the family caregiver of an older adult about measures to promote client safety in the home. Which of the following would be most appropriate to include?

"Clear the clutter from the stairways and walkways."

When the nurse is administering medication, an elderly client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

A nurse is preparing to file a safety event report after a patient experienced a fall. The nurse is aware that which statement below is correct regarding the filing of a safety event report?

The nurse should record the incident in the patient's medical record and fill out a safety event report separately.

A nurse has finished providing morning care for the client. What safety measures should the nurse employ prior to leaving the client's room? Select all that apply. - Place the bed in the lowest position. - Leave the client laying flat. - Test the functioning of the bed and bed control. - Place the call light near the client within reach. - Place all four side rails up. - Ensure the bed is locked. - Remove excess sheets from the room.

- Place the best in the lowest positon. - Test the functioning of the bed and bed control. - Place the call light near the client within reach. - Ensure the bed is locked.

A nurse is caring for a client with severe lower back pain. The doctor orders administration of an analgesic as a stat dose. When should the nurse administer the medication?

Immediately.

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. What is the purpose of the "read-back" requirements? Select all that apply. - to prohibit prescriptions and test results from being communicated verbally or by telephone. - to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information. - to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information. - to minimize the risk for non- authorized personnel from giving prescriptions that are communicated verbally or by telephone. - to encourage the use of electronic medical records.

- to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information. - to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.

Which of the following medication dosages is properly written?

0.25mg

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

A nurse is caring for elderly clients. Which of the following is the most important safety issue in older clients?

Accidental falls.

A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure that accuracy of the verbal medication order?

Ask the physician to write out the order.

A nurse caring for an 8-month-old infant diagnosed with respiratory syncytial virus is unable to read a medication dosage written in the infant's medical record. What is the only ethical and responsible solution for the nurse?

Call the physician and ask for verbal order to clarify the dosage.

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception.

A nurse enters a patient's room and finds that the patient has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this patient?

Document the incident, assessment, and interventions in the patient's medical record.

When the nurse recognizes that he has documented one client's assessment data on the wrong client's medical record, the nurse should

Draw a single line through the error, initial it, and write the correct entry.

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

Helmet.

In which way does a nurse play a key role in error prevention?

Identifying incorrect dosages or potential interactions of ordered medications.

A patient will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this patient?

If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patient's head.

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or a flame is dangerous near oxygen.

Which of the following flow sheets provides the health care provider with information on an ongoing record of fluid loss?

Intake and output graphic sheet.

The nurse is reinforcing education about child safety with the parents of a 6-month-old who is beginning to crawl. Which point should the nurse include in the education?

Keeping furniture with sharp corners out of the area where the infant crawls.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

Limiting abbreviations to those approved for use by the institution.

A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse control. The nurse caring for the client on the previous shift identified him at high risk for falls. While making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the client and notes no injuries. How should the nurse follow up on this incident?

Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the car plan needed as a result of the fall.

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?

Orienting clients to the surroundings decreases the potential for injury.

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 of the following measures would be a high priority recommendation for this client?

Placing the client in a bed with a bed alarm.

A nurse is working with clients with delirium on a medical unit. What is the nurse's priority concern?

Safe environment.

A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow?

Use abbreviations approved by the facility.