chapter 27

In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the 6. following actions should the nurse perform when applying and maintaining the restraints?

Tie the client's hand restraint to the bed frame rather than the side rail.

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her 8. risk of injury?

"Always test the temperature of bath water before stepping in."

What statement by a client would indicate that a nurse had successfully implemented a educating/learning strategy to 20. prevent injury in the home?

"I am going to remove all those throw rugs on the floor."

A girl age 4 years has been admitted to the emergency department after accidently ingesting a cleaning product. Which 5. of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning?

Administration of activated charcoal

A doctor orders restraints for an older adult client who is disoriented from the pain medication she is taking. Which of 26. the following is an appropriate guideline for applying these restraints?

Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and children under 9 years within D) one hour.

The facility risk management team is preparing an in-service to nursing staff members. The presentation will highlight risk factor increase related directly to the type of clientele on a nursing unit. The presenter will correctly explain that 23. which of the following risks is increased for female nurses who work on an oncology care unit?

Adverse reproduction

The nurse is caring for a client who has prescribed extremity restraints. The nurse is required to document which of the 24. following?

Alternative measures attempted before applying the restraints

A client arrives at the emergency department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed to the anthrax bacillus. What category of medications will be 19. administered?

Antimicrobials

Prior to inserting a nasogastric tube, the nurse correctly verifies the client's identity through which of the following 33. methods?

B) Check the client's identification bracelet.

Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who 34. leaves her toddler unattended in the bathtub?

B) Risk for Suffocation

A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a 13. recommended safety guideline for this age group?

Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of age.

Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an 15. appropriate intervention to prevent falls?

D) Lock wheels on beds and wheelchairs.

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is 25. a prudent nursing intervention for this client?

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

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education 1. sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents?

Educating nurses on how to prevent falls

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her 27. life. Which of the following statements describes an accurate action to take when applying these restraints?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

The nurse conducting a community emergency preparedness education class includes which of the following as an 35. example of a natural disaster?

earthquake

After a client falls out of bed, the nurse completes which of the following?

incident report

A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion of cleaning solution. 21. What must be included in educating parents about how to protect a toddler from accidental poisoning?

keep cleaning stuff locked up

Which of the following populations, bTasEedSoTn BtheAirNdeKveSloEpmLenLt EstaRge., wCoOuldMbenefit from strategies to prevent falls? 28. Select all that apply.

newborn toddlers older adults

What age group is most vulnerable to toxic fumes or asphyxiation?

young children

The nurse knows that a health care facility should determine its disaster-preparedness plan for delivering care in the 30. event of an emergency or disaster?

In advance of a possible emergency or disaster

What safety device for children is mandated by law in all 50 states?

Infant car seats and carriers

When educating parents of preschoolers, what is most important to include in your presentation?

Keep chemicals in a locked cabinet

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it 16. is filled out?

Maintain it according to agency policy.

A nurse is assessing a client who recently had a stroke. What is one area of assessment necessary to promote safety?

Neuromuscular

A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the 3. unit?

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

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has 12. been abused. What is legally required of the nurse?

Report suspicions about the abuse to proper authorities.

Which of the following measures should nurses implement in a hospital setting in order to identify intimate partner 2. violence (IPV)?

Routine screening of newly admitted clients

A client is very anxious and states, "I am so stressed." Why do these factors affect the client's safety?

Stress tends to narrow the attention span

A nurse specializes in caring for victims of domestic violence. Which of the following statements accurately describes 32. domestic violence in the United States? (Select all that apply.)

Studies indicate that each year, more than 12 million adults in the United States are victims of intimate partner violence. B) Intimate partner violence is domestic violence or battering between two people in a close relationship. C) Many men who batter their spouses also batter their children.

Bioterrorism has become a commonly used term. What is the definition of bioterrorism?

The deliberate spread of pathogens into a community

In what situation would the use of side rails not be considered a restraint?

A client requests they be up at night.

Which of the following clients is mosTt lEikeSlyTtoBfaAceNaKn iSncEreLaseLdErisRk.ofCfaOllsMdue to his or her medication regimen?

A female client age 77 years who has received a benzodiazepine to minimize her anxiety

An adolescent has recently had a ring inserted into her navel. Which of the following is the greatest risk facing the 14. adolescent as a result of this activity?

A local and/or systemic infection

Which of the following people has the greatest risk for accidental injury?

A worker who operates industrial machines