Chapter 28 - PrepU

Arrange for a skilled home care assessment (Explanation: The client's home should be evaluated for potential hazards and risks. There is no indication of vision or hearing issues. It is uncommon for falls to be directly attributable to osteoporosis.)

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Placing the client in a bed with a bed alarm

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 would be a priority recommendation for this client?

Report this sentinel event to The Joint Commission and to relevant state agencies.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

automobile accidents.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

Drowsiness Headache Vomiting

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. Drowsiness Fever Headache Increased thirst Vomiting

The hospital must bear any costs incurred for treating the client's injury.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

Conceal IV tubing with gauze wrap

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

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

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

New systems are introduced to increase communication between nurses and the members of other health disciplines.

A hospital is introducing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). What activity will benefit most directly from this initiative?

identifying systemic factors on the unit that may have contributed to the event

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A new parent inquires about the use of a car seat for their infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

Obtain a three-prong grounded plug adapter.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Childproofing the house

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

The nurse details the client's response and the examination and treatment of the client after the incident.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

Restrain the infant in a car seat.

A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan?

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

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

"Parents are effective role models for children when they also wear helmets while riding."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply.

Assessment includes risk factors in the home such as individual risk and unsafe environment.

A nurse making a home visit for a client living in a high-crime area observes that the apartment building does not have outside lighting. The nurse understands this is an important assessment for which reason?

Pull the fire alarm lever.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Rescue anyone who is in immediate danger.

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?

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

Involve family members in the client's care.

A nurse working in a long-term care facility is instituting interventions to prevent falls. Which intervention is an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

They may be the victim of cyber-bullying. (Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Puberty may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.)

A parent who is caring for their13-year-old child asks the nurse why they could be performing poorly in school lately, and why they are distancing themselves from friends and family. Which of these possibilities would the nurse consider as the priority risk?

administering medications to the client

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety?

keeping medications in clearly labeled containers

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching?

Investigate the possibility of discontinuing his or her catheter.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

"Make sure that you have smoke detectors in your house and that they're in working order."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

Assessment of vital signs and respiratory status

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

a dose of an antipsychotic

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

Anticipate the client's need to urinate, and assist to the toilet as appropriate.

An older adult client in the hospital has been deemed a risk for falls. What falls prevention measure should the nurse prioritize?

Provide a bedside commode and ensure adequate lighting.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Reduce distressing environmental stimuli to maximize client safety

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

The client will not experience a fall and remains free of injury.

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

dangling blind cords

The community health nurse is performing a home visit to a family with a toddler. Which observation should prompt the nurse to perform safety education?

polypharmacy and use of multiple extension cords.

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

injury risk related to agitation

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?

Communication ability Developmental level Mobility

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

The alternative measures attempted before applying the restraints

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

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

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?

Take the restraints off, stay with her, and talk gently to her

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Extremity restraint (Explanation: The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.)

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Assess the need for assistance with ambulation.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

"I should be able to fit two fingers between my chin and the chin strap."

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

poisoning risk related to poor eyesight and the inability to read medication labels

The nurse is creating a plan of care for an older adult client who takes multiple medications and a has difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing concern to include in this client's plan of care?

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

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?

Takes furosemide daily Admits to drinking wine through the evening Has history of diabetic neuropathy

The nurse is performing an assessment on an older adult. From which data does the nurse deduce that the client is at high risk for falls in the home? Select all that apply. Takes furosemide daily Admits to drinking wine through the evening Shares a one floor living space with a spouse Has history of diabetic neuropathy Participates in a walking club

safety with stairs water safety electric outlet safety childproof latches

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 bike safety

appropriate positioning in a crib

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Refrain from using extension cords.

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?

Encourage exercise that improves balance and muscle strength

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

value of not giving into social pressure to perform unsafe acts

The nurse is providing safety education to a group of adolescents. What teaching point should the nurse prioritize?

A hair dryer is placed next to the sink.

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?

"I will rescue clients from harm before doing anything else."

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

"Only certain members of the health care team can extinguish a fire."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

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

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?

Client-centered care Teamwork and collaboration Quality improvement (QI) (Explanation: The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.)

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. Client-centered care Teamwork and collaboration Establishment of clinical career ladders Revamping the licensing requirements for foreign-educated nurses Quality improvement (QI)

Use night-lights in bedrooms and bathrooms.

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?

Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms in which the client may wander. Encourage the client to toilet prior to bedtime. Place locks on any doors to the outside that the client would be able to open.

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply.

"Check breathing and heart rate."

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

"Is your child breathing at this time?"

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?

experimentation with drugs and inhalants

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

Open doors and windows.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Initiate use of a bed alarm.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Fifth

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

Rescue the client.

Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority?

Safety is a paramount concern underlying all nursing care.

What generalization can be made about safety in client care?

Providing prompt recognition of the potential or actual threat to safety

What is the primary role of the nurse in the care of clients who experience domestic violence?

Orienting clients to the surroundings decreases the potential for injury.

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

Have a meeting place outside the home in case of fire.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes. (Explanation: The QSEN concept of quality improvement recommends use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes.)

Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply.

provides slippers for ambulation

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?

84-year-old client with four recent driving violations

Which client will the nurse assess for sensory-perceptual alterations?

nurse practitioner

Which level of health care provider may make the decision to apply physical restraints to a client?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?