Chapter 19 Safety Prep U

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse is caring for a client who has been physically restrained due to extremely aggressive and violent behavior. While conducting the client assessment, which finding(s) will lead the nurse to remove with restraints temporarily? Select all that apply.

The client has a respiratory rate of 10 breaths/min. The client has been incontinent of urine in bed. The nurse will monitor a physically restrained client closely and assess frequently. Signs of distress or discomfort should lead the nurse to remove the restraints with assistance to fully meet the client's needs or prevent undue harm. A client who is incontinent of urine in the bed is unable to reposition oneself and is at risk for impaired skin integrity. The nurse will remove the restraints with assistance from additional care team members and provide hygiene and skincare to the client as needed. The nurse also will offer the client a commode or support ambulating to the bathroom prior to applying the restraints if they are still required. Any change in the client's vital signs should be noted and the appropriate intervention employed. For a client with a respiratory rate of 10 breaths/min, the nurse will remove the restraints to perform a comprehensive and focused respiratory assessment. The client may require urgent intervention. A capillary refill of 2 seconds is normal and does not indicate poor circulation or perfusion. A blood pressure of 120/75 mm Hg is considered normal and would not be concerning. Physical restraints can be applied in a way that allows the client to be able to continue to drink assisted from a straw to meet needs for adequate fluid intake.

The nurse has just admitted a client preoperatively to a surgical unit. The client will undergo a surgical procedure the following day. After reviewing the chart, the nurse will prioritize communication to the care team regarding what client data?

The client has had an anaphylactic response to latex products.

A nurse is providing a safety program on childhood poisoning for a group of parents of preschool and school-age children. The nurse determines that the education was successful when the makes which statement?

"Berries and seeds that children find out in the woods are not safe for them to eat." It is unsafe to let children eat berries, seeds, mushrooms, or plants found in the outdoors, as they may be poisonous. Tulips and daffodils are not safe houseplants; they are poisonous plants. Ipecac syrup is no longer recommended to induce vomiting in suspected ingestion of poisons. Instead, the adult should call the poison control center for instructions. Household chemical products should not be removed from the original container and stored in plastic bags. Rather, they should be kept in their original containers with warning labels and emergency information intact.

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

"I have removed all throw rugs on the floor."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else." The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue clients first.

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

The nurse is presenting content on fire safety to a family. One of the family members tells the nurse that they have designated a meeting spot in their front yard in case of fire and that they practice using escape routes. Which is the nurse's best response?

"That's an important part of an overall fire safety plan."

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?

19-year-old male college student majoring in physics

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 hair dryer is placed next to the sink.

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

Apply an allergy-alert identification bracelet on the client. The priority is to apply an allergy-alert bracelet to the client so that any member of the interdisciplinary team can quickly identify the latex allergy. All other actions can take place immediately thereafter.

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat. Nurses should teach older clients ways to prevent falls at home. They include the following: Clean up clutter. Repair or remove tripping hazards. Install grab bars and handrails. Avoid wearing loose clothing. Lighting should be bright. Wear shoes and make them nonslip. Live on one level. The use of an electronic personal alarm is not a product that would prevent falls.

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

Call Nutrition Services for a plain hamburger. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will need to obtain a hamburger without tomato on it for the client with a latex allergy.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors. For older adult clients with cognitive impairment, such as when clients are diagnosed with dementia or Alzheimer disease, the tendency to wander can pose a serious risk to the client's safety. In the nurse's plan of care for this client, it is necessary to ensure the client's environment is assessed for and adapted to prevent the client from exiting the care facility unaccompanied. The nurse will place STOP signs on all exit doors to communicate to the client that the client should not open exit doors. The nurse can ensure there is a bell over the client's room door so there is an audible signal to care providers when the client is out of the room. Physical restraint is an intervention that is used sparingly with clients with cognitive impairment because it is invasive and traumatizing. The application of physical restraint is reserved for situations in which the client is placing one's own safety in danger. An intervention such as this would not be used periodically throughout the day. The nurse will implement nonviolent crisis intervention such as therapeutic communication, redirection and occasionally chemical restraints if the client is sufficiently agitated to place oneself or others at risk. Security personnel can be perceived as threatening by the client, and their presence could lead to further agitation and long-term harm to the client. The presence of security is required only on a case-by-case basis. The client should only take a walk outdoors if accompanied by a care provider or family member.

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a bonfire, what will the nurse identify?

Class A

A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire?

Class C

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

Contact the health care provider to clarify the orders. Before treatments can safely be carried out and medications safely given, the nurse must contact the health care provider to clarify the orders. Many abbreviations and symbols are not permitted for use in health care records. The nurse should never alter documentation, nor is it appropriate to confirm abbreviations with another nurse.

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

Dilute with water or milk. The decision tree for treating ingested poisons states that if petroleum is ingested, it should be diluted with water or milk, vomiting should be prevented, hydration should be given, and symptoms should be treated. Therefore, it is not appropriate to call 911, induce vomiting, or administer a laxative.

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

Educating nurses on how to prevent falls Falls remain the leading cause of death among older adults. Education that aims to reduce the incidence of falls is likely to be of more benefit than measures that address medication administration, prevention of wandering, or resuscitation procedures, even though such topics may be of importance.

A client has presented to the emergency department after splashing a caustic chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes. If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.

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

Implement drowning prevention strategies. The principles of injury control have interventions centered at three primary levels: the individual level--providing education about safety hazards and prevention strategies; the design phase--using engineering and environmental controls; and the regulatory level--creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. Although the nurse's role would fit into the individual level of providing education, it is not the nurse's responsibility to teach cardiopulmonary resuscitation or swimming in this scenario. As the nurse's role does not include the design phase or regulatory level, it is not a nursing responsibility to require fencing around all pools.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns. Most people who die in house fires die of smoke inhalation rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

The older adult client was admitted to the emergency department for accidentally overdosing on a prescribed medication. The client is prescribed several medications that have varying frequencies for administration. The nurse is providing tips to the client to prevent such an occurrence from happening again. What instructions would the nurse provide to the client? Select all that apply.

Place pills in a pill dispenser that provides for separate dosing throughout the day. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Contact the pharmacist or primary care provider about questions regarding medications. Request large-print medication labels on each of the prescribed medication bottles.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords. Extension cords should not be used so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action?

Replace common health care items with latex-free equipment.

Which measure would be most effective at protecting a toddler from accidental poisoning due to the ingestion of medication?

Request childproof caps on all prescription medications.

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?

Rescue anyone who is in immediate danger.

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

True

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation.

The 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?

Use night-lights in bedrooms and bathrooms. The risk of falls increases with a person of advanced age, impaired mobility, or both. Ways to prevent falls include the use of night-lights in bedrooms and bathrooms to provide light if the client needs to get up in the night. Other interventions include removal of throw rugs, making sure that stairways are well-lit (100 watt bulbs), and never attempting to reach items that are beyond reach or physical ability. There are many benefits to physical mobility so the client should be encouraged to ambulate with safety measures, not to avoid ambulating altogether.

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

Wash hands thoroughly after removing gloves with a pH balanced soap. If latex gloves are used, nurses should wash hands thoroughly after removing gloves with a pH-balanced soap. They should use powder-free, not powdered, gloves. They should not snap gloves when applying them. They should avoid using oil-based hand creams or lotions.

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?

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

The nurse is participating in the investigation of a series of Centers for Medicare & Medicaid Services (CMS) "never events" that have taken place over the past several months. Which clinical event will the nurse most likely investigate?

an increase in the incidence and prevalence of pressure injuries experienced by clients

The school nurse is providing education on poisoning risks to adolescent students. Which topic does the nurse include in the teaching?

experimentation with drugs and inhalants.

A fire has erupted in a trash can on the unit. The nurse obtains the fire extinguisher and is preparing to use it. Arrange the sequence of steps that the nurse should follow. Use all options.

pull the pin, aim the nozzle, squeeze the handle, sweep back and forth

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

raising all side rails while the client is in bed Raising all side rails on the bed would be a restraint and may increase the client's risk of falling if he climbs out of bed. All the other options would comply with a least restraint policy.

The nurse is preparing an education session on injury prevention for parents with toddlers. What will the nurse prioritize during this session to help parents to reduce the risk of injury for toddler, given their developmental stage? Select all that apply.

safety with stairs water safety electric outlet safety childproof latches Infants and toddlers are vulnerable and often the victims of accidental poisoning, falls from stairs or high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. As children do not begin to learn how to ride a bike independently until at least the preschool age (more commonly during the school-aged years), the nurse will not prioritize teaching the parents about bike helmet safety.

The nurse is working at a local elementary school. A parent arrives to pick up their 6-year-old son and is accompanied by their 2-year-old child.. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom

A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?

using carbon monoxide detectors and alarms

The nurse is assessing clients for risk factors in the workplace. Which client(s) is at risk for injury due to the environment of the workplace? Select all that apply.

worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns unlicensed assistive personnel who lifts clients in a long-term care facility