ADN140 Safe Practice

You are reviewing a patient's newly written medication order and are unable to read the prescriber's handwriting. Which of the following actions by is most appropriate?

Contact the prescriber to clarify the order.

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

Identifying incorrect dosages or potential interactions of ordered medications

A nurse is assigned to care for a hospitalized toddler. Which of the following activities should be the highest priority for the nurse?

Protect the toddler from injury

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which of the following actions should the nurse take to best ensure the safety of the client while complying with policy?

Provide a bed that is low to the floor.

Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which of the following statements indicates the primary reason for the nurse manager to perform an investigation to determine the causes of the two falls?

"I would like to establish the causes and trends related to client falls."

A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair?

45 degrees to the bed on the left side

You are caring for an adult patient on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which of the following initial interventions is appropriate?

Assess for the need to urinate

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

Falls

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs.

A nurse is admitting a patient to a geriatric medicine unit following the patient's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the patient's chance of experiencing a fall while on the unit?

Orient the patient to the room and environment thoroughly upon admission.

A nurse is placing an infant in a mummy restraint in order to perform eye care. Which of the following is a recommended guideline for application of a mummy restraint?

Place the child on the blanket, with edge of blanket at or above neck level.

Mr. Ames, age 84, has just been admitted to the hospital for the treatment of pneumonia. In addition to this diagnosis, Mr. Ames also has stage II Alzheimer's disease and is disoriented to place and time. As the night has progressed, he has become increasingly agitated, pulling out his intravenous catheter and wandering throughout the unit. He has become more agitated as the nurses have attempted to reorient and redirect him. Which of the following interventions should the nurses perform?

Position Mr. Ames' bed closer to the nurses' station and perform an assessment.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures does not comply with a least restraint policy?

Raising all side rails while the client is in bed

A client has developed neuropathy as he has aged. What would be the most important teaching intervention for the client and family?

Reduce the temperature on the water heater

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents?

Teaching nurses how to prevent falls

A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which of the following should the nurse consider while assisting the client?

The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained.

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.

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

True

The charge nurse is observing a new nurse care for a patient who is at high risk for falls. Which of the following actions by the new nurse would require the charge nurse to intervene?

Waiting outside of the closed bathroom door while the patient uses the toilet

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:

assess the client for pain.

The nurse is preparing a client for nonemergency surgery. The nurse should:

verify the client understands the informed consent form.

Which of the following populations would benefit from fall prevention strategies based on their developmental stage? Select all that apply.

• Newborns • Older Adults • Toddlers

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which of the following actions by the nurse would be appropriate? Select all that apply.

• Perform a face-to-face behavior evaluation every hour. • Tie the restraints in quick-release knots. • Document the client's condition. • Document alternative methods used before the restraints were applied. • Document the client's response to the intervention.